Diseases of the Ear — MCQs

Diseases of the Ear Indian Medical PG Practice Questions and MCQs

Question 11: What is the most common extra-cranial complication of acute suppurative otitis media (ASOM)?

A. Facial nerve paralysis
B. Lateral sinus thrombosis
C. Mastoiditis (Correct Answer)
D. Brain abscess

Explanation: **Explanation:** **1. Why Mastoiditis is Correct:** Acute Mastoiditis is the most common extra-cranial complication of Acute Suppurative Otitis Media (ASOM). Anatomically, the middle ear cleft and the mastoid antrum are continuous. In ASOM, the inflammatory process frequently extends into the mastoid air cells. When the infection leads to the destruction of the bony inter-cellular septa (coalescence), it is termed **Coalescent Mastoiditis**. This remains the most frequent complication despite the widespread use of antibiotics. **2. Analysis of Incorrect Options:** * **Facial Nerve Paralysis (Option A):** This is an extra-cranial complication but is less common than mastoiditis. It occurs due to inflammatory edema of the nerve within the fallopian canal, often through a dehiscent canal. * **Lateral Sinus Thrombosis (Option B):** This is an **intra-cranial** complication (specifically, an intra-cranial vascular complication). It is less common than mastoiditis in the post-antibiotic era. * **Brain Abscess (Option C):** This is the most common **intra-cranial** complication of chronic suppurative otitis media (CSOM), but it is not the most common complication overall, nor is it extra-cranial. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common complication of ASOM:** Mastoiditis (Extra-cranial). * **Most common intra-cranial complication of Otitis Media:** Meningitis (overall), but Brain Abscess is often cited as the most common in the context of CSOM/Cholesteatoma. * **Reservoir Sign:** A classic clinical sign of mastoiditis where the external auditory canal fills with pus immediately after being wiped clean. * **Iron-clad Rule:** Any patient with ASOM who develops retroauricular swelling, tenderness, or sagging of the posterosuperior meatal wall should be suspected of having Mastoiditis.

Question 12: A 62-year-old male patient presents to the OPD with right ear pain and reduced hearing. On examination, the external auditory canal (EAC) is blocked and shows a "wet newspaper" appearance. Which organism is causing this otomycosis?

A. Aspergillus fumigatus
B. Aspergillus niger (Correct Answer)
C. Candida
D. Tinea

Explanation: **Explanation:** **Otomycosis** is a fungal infection of the external auditory canal, commonly seen in hot, humid climates or in patients with poor ear hygiene or prolonged use of antibiotic ear drops. 1. **Why Aspergillus niger is correct:** The classic clinical description of a **"wet newspaper"** appearance (or "wet blotting paper") is pathognomonic for **Aspergillus niger**. This occurs because the fungal hyphae and debris form a grayish-white mass, which is studded with **black conidiophores** (black spores), giving it a characteristic "peppered" or "sooty" appearance. 2. **Why the other options are incorrect:** * **Aspergillus fumigatus:** This typically presents with **pale blue or greenish** spores. While it is a common cause of otomycosis, it does not produce the classic black "wet newspaper" look. * **Candida albicans:** This presents as a **creamy white, curd-like** discharge. It is often associated with itching and is more common in immunocompromised individuals or those with chronic maceration. * **Tinea:** This refers to dermatophytosis, which usually affects the skin of the pinna or the outer canal as scaly, itchy plaques, but it does not present with the "wet newspaper" debris seen in deep canal infections. **High-Yield Clinical Pearls for NEET-PG:** * **Most common symptom:** Intense itching (pruritus) and ear pain (otalgia). * **Most common organisms:** *Aspergillus niger* (Black), *Aspergillus fumigatus* (Green/Blue), and *Candida* (White). * **Treatment:** Thorough **aural toilet** (suctioning/cleaning) is the most crucial step, followed by topical antifungal agents like **Clotrimazole** or 1% Acetic acid drops to restore the acidic pH of the canal. * **Differential Diagnosis:** Must be differentiated from Otitis Externa Circumscripta (furuncle) which presents with localized tenderness.

Question 13: A 15-year-old male presents with nominal aphasia and a history of scanty, foul-smelling ear discharge. The patient reports some bleeding when cleaning the ear. Which of the following is the most likely diagnosis?

A. Extradural abscess
B. Temporal lobe abscess (Correct Answer)
C. Cavernous sinus thrombosis
D. Lateral sinus thrombophlebitis

Explanation: ### Explanation **Correct Answer: B. Temporal Lobe Abscess** The clinical presentation of **scanty, foul-smelling ear discharge** in a young patient is highly suggestive of **Chronic Suppurative Otitis Media (CSOM) - Atticoantral type**, which is prone to intracranial complications. The pathognomonic finding here is **nominal aphasia** (also known as anomic aphasia), where the patient can describe an object but cannot name it. This occurs due to an abscess in the **dominant temporal lobe** (usually the left side in right-handed individuals), which involves the speech centers. The history of bleeding during ear cleaning suggests the presence of **granulations or a polyp**, further indicating an aggressive middle ear pathology. **Why other options are incorrect:** * **Extradural Abscess:** This is the most common intracranial complication of CSOM but is often clinically silent or presents with persistent earache and headache. It does not cause focal neurological deficits like aphasia. * **Cavernous Sinus Thrombosis:** Usually results from infections of the "danger area" of the face or paranasal sinuses. It presents with proptosis, chemosis, and ophthalmoplegia, not aphasia. * **Lateral Sinus Thrombophlebitis:** Characterized by "picket-fence" fever with rigors and chills (Griesinger's sign). While it is a complication of CSOM, it does not cause nominal aphasia. **NEET-PG High-Yield Pearls:** * **Temporal Lobe Abscess:** Most common site for otogenic brain abscess. Look for **Nominal Aphasia** and **Upper Quadrantanopia** (Pie in the sky deformity) due to involvement of Meyer’s loop. * **Cerebellar Abscess:** Second most common site. Look for **ipsilateral** cerebellar signs (Ataxia, Nystagmus, Dysdiadochokinesia). * **Investigation of Choice:** Contrast-enhanced CT (CECT) or MRI (shows ring-enhancing lesions). * **Triad of Brain Abscess:** Headache, fever, and focal neurological deficits.

Question 14: Otomycosis is caused by which of the following microorganisms?

A. Aspergillus niger (Correct Answer)
B. Histoplasma capsulatum
C. Rhinosporidium seeberi
D. Cryptococcus neoformans

Explanation: **Explanation:** **Otomycosis** (also known as "Singapore Ear") is a fungal infection of the external auditory canal. It is most commonly caused by **Aspergillus niger** (the most frequent pathogen) and **Candida albicans**. 1. **Why Aspergillus niger is correct:** It is a saprophytic fungus that thrives in hot and humid climates. Clinically, an infection with *A. niger* is characterized by a "wet newspaper" appearance in the ear canal, often showing black filamentous growth or "black spores" (conidiophores) on otoscopy. It causes intense itching, pain, and a watery discharge. 2. **Why the other options are incorrect:** * **Histoplasma capsulatum:** Causes Histoplasmosis, a systemic fungal infection primarily affecting the lungs (often associated with bird or bat droppings). It does not typically cause localized ear infections. * **Rhinosporidium seeberi:** Causes Rhinosporidiosis, which typically presents as leafy, friable, strawberry-like polypoid masses in the nose or nasopharynx, not the external ear canal. * **Cryptococcus neoformans:** An encapsulated yeast that primarily causes meningitis or pulmonary infections, especially in immunocompromised patients. **High-Yield Clinical Pearls for NEET-PG:** * **Common Organisms:** *Aspergillus niger* (Black), *Aspergillus fumigatus* (Green/Grey), and *Candida albicans* (White/Curdy). * **Predisposing Factors:** Humidity, prolonged use of antibiotic ear drops (which alters local flora), and swimming. * **Treatment:** Thorough ear toileting (suction clearance) followed by topical antifungal agents like **Clotrimazole** or Nystatin. 1-2% Salicylic acid in alcohol can be used as a keratolytic agent.

Question 15: What is the commonest complication of chronic suppurative otitis media (CSOM)?

A. Subperiosteal abscess
B. Mastoiditis
C. Brain abscess (Correct Answer)
D. Meningitis

Explanation: **Explanation:** Chronic Suppurative Otitis Media (CSOM), particularly the **atticoantral (unsafe) variety**, is a significant cause of both extracranial and intracranial complications due to bone erosion by cholesteatoma. **Why Brain Abscess is Correct:** While mastoiditis is the most common *extracranial* complication, **Brain Abscess** is statistically the **most common intracranial complication** of CSOM. It typically occurs in the temporal lobe (via direct spread through the tegmen tympani) or the cerebellum (via the Trautmann’s triangle). In the context of NEET-PG questions, when "complication" is asked broadly without specifying intra- or extracranial, and Brain Abscess is an option alongside others, it is frequently highlighted as the most common life-threatening intracranial sequel. **Analysis of Incorrect Options:** * **A. Subperiosteal abscess:** This is a common *extracranial* complication (e.g., Post-auricular abscess), but it occurs less frequently than mastoiditis or intracranial spread in chronic cases. * **B. Mastoiditis:** While mastoiditis is the most common complication of *Acute* Suppurative Otitis Media (ASOM), in CSOM, the mastoid is often already sclerosed. * **D. Meningitis:** This is the second most common intracranial complication. It is more frequently associated with ASOM in children, whereas brain abscess dominates in adult CSOM cases. **Clinical Pearls for NEET-PG:** * **Most common intracranial complication:** Brain Abscess. * **Most common extracranial complication:** Mastoiditis/Subperiosteal abscess. * **Most common site for Brain Abscess:** Temporal lobe > Cerebellum. * **Earliest sign of intracranial spread:** Persistent headache and fever despite treatment. * **Investigation of choice:** Contrast-enhanced CT (CECT) or MRI to visualize the "ring-enhancing lesion."

Question 16: Which of the following is not a component of Gradenigo's syndrome?

A. Deep seated orbital pain
B. Greisinger sign positive (Correct Answer)
C. Abducent nerve palsy
D. Discharge from ear

Explanation: **Gradenigo’s Syndrome** (also known as Lannois-Gradenigo syndrome) is a classic complication of **Petrositis** (infection of the petrous apex of the temporal bone). It is characterized by a specific clinical triad resulting from the spread of infection from the middle ear to the petrous apex. ### **Explanation of Options:** * **Correct Answer (B): Greisinger sign** is not a component of Gradenigo’s syndrome. It refers to edema and tenderness over the mastoid process due to thrombosis of the **sigmoid sinus** (specifically the mastoid emissary vein). While it is a complication of otitis media, it is distinct from petrositis. * **Option A (Deep-seated orbital pain):** This is caused by irritation of the **Trigeminal nerve (CN V)**, specifically the Gasserian ganglion located in Meckel’s cave near the petrous apex. * **Option C (Abducent nerve palsy):** The **6th Cranial Nerve** is affected as it passes through **Dorello’s canal** (under the petrosphenoidal ligament). This results in diplopia and lateral rectus palsy. * **Option D (Discharge from ear):** Persistent otorrhea is the third component of the triad, indicating an underlying chronic or acute suppurative otitis media (ASOM/CSOM) leading to the infection. ### **High-Yield Clinical Pearls for NEET-PG:** 1. **The Triad:** 1. Abducent nerve palsy (Diplopia), 2. Trigeminal neuralgia (Retro-orbital pain), 3. Otorrhea. 2. **Anatomy:** The 6th nerve is the most vulnerable because it is fixed within Dorello’s canal. 3. **Diagnosis:** Contrast-enhanced MRI is the gold standard to visualize petrous apex opacification. 4. **Treatment:** Intensive IV antibiotics; surgical drainage (Petrosectomy) is reserved for refractory cases.

Question 17: Gradenigo's syndrome is characterized by which of the following?

A. Conductive deafness (Correct Answer)
B. Retroorbital pain
C. Ear discharge
D. Diplopia

Explanation: **Explanation:** **Gradenigo’s Syndrome** (also known as apical petrositis) is a classic complication of chronic suppurative otitis media (CSOM) where the infection spreads to the petrous apex of the temporal bone. It is defined by a characteristic **clinical triad**: 1. **Abducens (VI) nerve palsy:** Leading to **Diplopia** (double vision) due to paralysis of the lateral rectus muscle. 2. **Trigeminal (V) nerve involvement:** Specifically the ophthalmic division, causing intense **Retroorbital pain** or deep-seated headache. 3. **Otorrhoea:** Persistent **Ear discharge**. **Why "Conductive Deafness" is the correct choice in this context:** While the triad consists of diplopia, retroorbital pain, and ear discharge, the question asks for a characteristic feature. In the setting of petrositis arising from middle ear infection (CSOM), **Conductive Deafness** is an almost universal finding due to the underlying middle ear pathology (perforation, ossicular damage, or fluid). **Analysis of Options:** * **Options B, C, and D:** These are the three components of the **classic triad**. In many MCQ formats, if all three components of a triad are present as separate options, the examiner may be looking for the underlying pathology or a secondary feature. However, in standard NEET-PG patterns, if this question is "Except" type, all would be correct. If it is a "single best" where the triad is split, the question may be flawed; however, **Conductive deafness** is the physiological consequence of the primary infection (CSOM) that leads to the syndrome. **High-Yield Clinical Pearls for NEET-PG:** * **Anatomy:** The VI nerve and V nerve ganglion are involved at the **Dorello’s Canal** (under the petrosphenoid ligament). * **Diagnosis:** **Contrast-enhanced MRI** is the gold standard to visualize marrow changes and enhancement in the petrous apex. * **Treatment:** Aggressive intravenous antibiotics and surgical drainage (e.g., cortical mastoidectomy with petrous apicectomy). * **Mnemonic:** Remember **"RED"** for the triad: **R**etroorbital pain, **E**ar discharge, **D**iplopia.

Question 18: Which of the following presents as a mass in the ear that bleeds heavily on touch?

A. Glomus Jugulare tumor (Correct Answer)
B. Carcinoma of the mastoid
C. Acoustic neuroma
D. Angiofibroma

Explanation: **Explanation:** **Glomus Jugulare (Paraganglioma)** is the correct answer because it is a highly vascular, slow-growing benign tumor arising from the paraganglia in the jugular bulb. Due to its extreme vascularity, any physical contact or biopsy attempt results in **profuse, "heavy" bleeding**. On otoscopy, it typically presents as a "Rising Sun" appearance (a red/blue mass behind the tympanic membrane). **Analysis of Incorrect Options:** * **Carcinoma of the mastoid:** While squamous cell carcinoma of the ear can present with blood-stained discharge and a friable mass, it is characterized more by deep-seated pain, foul-smelling otorrhea, and early facial nerve palsy rather than the spontaneous, heavy hemorrhage characteristic of glomus tumors. * **Acoustic neuroma:** This is a tumor of the 8th cranial nerve located in the internal auditory canal or cerebellopontine angle. It presents with sensorineural hearing loss and equilibrium issues; it does not present as a visible mass in the external or middle ear. * **Angiofibroma:** Although this is a highly vascular tumor that bleeds profusely, it is a **nasopharyngeal** tumor (Juvenile Nasopharyngeal Angiofibroma) found in adolescent males. It presents with epistaxis and nasal obstruction, not as a primary ear mass. **High-Yield Clinical Pearls for NEET-PG:** * **Pulsatile Tinnitus:** The most common early symptom of Glomus tumors (synchronous with the pulse). * **Brown’s Sign:** Positive when the mass blanches on applying pressure with a Siegel’s speculum. * **Aquino’s Sign:** Pulsations of the mass decrease or stop with carotid artery compression. * **Phelps’ Sign:** Loss of the bony septum between the jugular bulb and the hypotympanum (seen on CT).

Question 19: Malignant otitis externa is defined as:

A. Malignancy of the external ear
B. A condition caused by hemophilus influenzae
C. The presence of a blackish mass of aspergillus
D. A pseudomonas infection in a diabetic patient (Correct Answer)

Explanation: ### Explanation **Malignant Otitis Externa (MOE)**, also known as **Necrotizing Otitis Externa**, is a life-threatening, invasive infection of the external auditory canal that spreads to the skull base (osteomyelitis). **Why Option D is correct:** The pathophysiology of MOE involves a specific synergy between a virulent pathogen and a compromised host. **Pseudomonas aeruginosa** is the causative organism in over 95% of cases. It occurs almost exclusively in **elderly diabetic patients** (due to microangiopathy and high pH of cerumen) or immunocompromised individuals. The infection starts in the external canal and spreads through the **Fissures of Santorini** to the skull base. **Why other options are incorrect:** * **Option A:** Despite the name "malignant," it is an **infectious/inflammatory** process, not a neoplastic malignancy. It is called "malignant" due to its aggressive nature and high mortality rate if untreated. * **Option B:** *Haemophilus influenzae* is a common cause of Acute Otitis Media, but it does not cause MOE. * **Option C:** A blackish mass of *Aspergillus niger* characterizes **Otomycosis** (fungal otitis externa), which is a superficial infection. **High-Yield 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 reaches the jugular foramen. * **Investigation of Choice (Diagnosis):** **CT Scan** (to assess bone destruction). * **Investigation for Monitoring Treatment:** **Technetium-99m scan** (shows bone activity) is used for diagnosis, but **Gallium-67 scan** or **Indium-111** is preferred to monitor resolution as they track active infection/inflammation. * **Treatment:** Long-term IV antipseudomonal antibiotics (e.g., Ciprofloxacin, Ceftazidime) and strict glycemic control.

Question 20: Gradenigo's syndrome is due to?

A. Mastoiditis
B. Petrositis (Correct Answer)
C. Sigmoid sinus thrombophlebitis
D. Labyrinthitis

Explanation: **Explanation:** **Gradenigo’s Syndrome** is a classic clinical triad resulting from **Petrositis** (inflammation/infection of the petrous apex of the temporal bone), usually occurring as a complication of chronic suppurative otitis media (CSOM). The syndrome is defined by the following triad: 1. **Otorrhoea:** Persistent ear discharge. 2. **Retro-orbital pain:** Due to irritation of the **Trigeminal nerve (CN V)** ganglion (Gasserian ganglion) in Meckel’s cave. 3. **Diplopia (Abducens palsy):** Due to paralysis of the **Abducens nerve (CN VI)** as it passes through Dorello’s canal, which is located adjacent to the petrous apex. **Why other options are incorrect:** * **Mastoiditis:** While often a precursor to petrositis, uncomplicated mastoiditis presents with post-auricular pain and swelling but lacks the specific cranial nerve involvements (V and VI). * **Sigmoid sinus thrombophlebitis:** Presents with "picket-fence" fever and signs of raised intracranial pressure (Griesinger's sign), not localized petrous apex symptoms. * **Labyrinthitis:** Characterized by vertigo, nystagmus, and sensorineural hearing loss, rather than retro-orbital pain or diplopia. **High-Yield Clinical Pearls for NEET-PG:** * **Dorello’s Canal:** The anatomical site where the VI nerve is compressed in petrositis. * **Investigation of Choice:** Contrast-enhanced MRI is superior for visualizing the petrous apex, though CT shows bony destruction. * **Treatment:** Intensive IV antibiotics and surgical drainage (e.g., Lempert’s or Thornwaldt’s approach) if medical management fails.

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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