Diseases of the Ear Practice Questions

Q: A patient presents with ear discharge. The CT image is shown below. Based on the clinical presentation and imaging, what is the most likely diagnosis?

Temporal lobe abscess. ***Temporal lobe abscess*** - The CT scan shows a **ring-enhancing lesion** in the **temporal lobe**, which is characteristic of a brain abscess. - **Ear discharge** (otorrhea), particularly from otitis media, is a common predisposing factor for temporal lobe abscesses due to the proximity of the middle ear and mastoid to the temporal lobe. - Otogenic brain abscesses account for a significant proportion of intracranial complications from ear infections, with the temporal lobe being the most common location. *Extradural abscess* - An **extradural abscess** would typically be located between the dura mater and the skull, often presenting as a **lenticular or biconvex collection** displacing the dura and brain, not within the brain parenchyma as seen here. - While ear infections can lead to extradural abscesses, the imaging clearly shows an intraparenchymal lesion. *Cerebellar abscess* - A **cerebellar abscess** would be located in the cerebellum (posterior fossa), which is a different anatomical location from the lesion seen in the image (which is in the supratentorial compartment, consistent with the temporal lobe). - Although ear infections can also lead to cerebellar abscesses, the lesion's position on the CT scan does not correspond to the cerebellum. *Meningitis* - **Meningitis** is an inflammation of the meninges and typically manifests on CT as **leptomeningeal enhancement**, particularly in the sulci and basal cisterns, rather than a discrete, encapsulated mass lesion like an abscess. - While ear discharge can be associated with meningitis, the imaging findings strongly point to an abscess, not diffuse meningeal inflammation.

Q: A patient with a history of chronic ear infection now presents with manifestations, including headache and vomiting. A CT brain image is shown. What is the most probable diagnosis?

Temporal lobe Abscess. ***Temporal lobe Abscess*** - The CT scan shows a **ring-enhancing lesion** with significant surrounding edema, which is characteristic of a **brain abscess**. - Given the history of a **chronic ear infection**, the temporal lobe is a common site for bacterial spread from the mastoid air cells or middle ear. *Meningitis* - Meningitis involves inflammation of the **meninges** and typically presents with diffuse changes on imaging, such as sulcal effacement or leptomeningeal enhancement, rather than a focal, encapsulated lesion. - While it can cause headache and vomiting, the CT image does not show findings typical of meningitis. *Extradural Abscess* - An extradural (or epidural) abscess is located **between the dura mater and the skull bone**. - It would typically appear as a collection outside the brain parenchyma, potentially causing mass effect but distinct from an intraparenchymal lesion seen in the image. *Cerebral Abscess* - The image does show a **cerebral abscess**, but this option is less specific than "Temporal lobe abscess." - The question asks for the **most probable diagnosis**, and combining the imaging findings with the patient's history of ear infection points to a specific location within the cerebrum.

Q: A 72-year-old man presents to his primary care physician with progressively worsening hearing loss. He states that his trouble with hearing began approximately 7-8 years ago. He is able to hear when someone is speaking to him; however, he has difficulty with understanding what is being said, especially when there is background noise. In addition to his current symptoms, he reports a steady ringing in both ears, and at times experiences dizziness. Medical history is significant for three prior episodes of acute otitis media. Family history is notable for his father being diagnosed with cholesteatoma. His temperature is 98.6°F (37°C), blood pressure is 138/88 mmHg, pulse is 74/min, and respirations are 13/min. On physical exam, when a tuning fork is placed in the middle of the patient's forehead, sound is appreciated equally on both ears. When a tuning fork is placed by the external auditory canal and subsequently on the mastoid process, air conduction is greater than bone conduction. Which of the following is most likely the cause of this patient's symptoms?

Cochlear hair cell degeneration. ***Cochlear hair cell degeneration*** - The patient's **progressive, bilateral hearing loss** over several years, difficulty understanding speech in noise, and **tinnitus** are classic symptoms of **presbycusis**, which results from age-related **degeneration of cochlear hair cells**. - The **normal Weber test** (no lateralization) and **Rinne test** (air conduction > bone conduction) indicate a **sensorineural hearing loss**, consistent with cochlear pathology rather than conductive issues. *Stapedial abnormal bone growth* - This condition (**otosclerosis**) causes **conductive hearing loss** due to fixation of the stapes, which would present with an **abnormal Rinne test** (bone conduction > air conduction) in the affected ear. - While it can cause progressive hearing loss and tinnitus, the normal Rinne test contradicts this diagnosis. *Endolymphatic hydrops* - This is the underlying pathology of **Ménière's disease**, which typically presents with episodic vertigo, fluctuating sensorineural hearing loss, tinnitus, and aural fullness. - The patient's dizziness is non-episodic, and the absence of fluctuating hearing loss and aural fullness makes Ménière's less likely. *Accumulation of desquamated keratin debris* - This describes a **cholesteatoma**, which typically causes **conductive hearing loss** and often presents with otorrhea, earache, and possibly vestibular symptoms. - The normal Rinne test (indicating sensorineural loss) and lack of otorrhea or earache make cholesteatoma unlikely, despite a family history.

Q: Mainstay of treatment of glue ear -

Myringotomy + aeration to middle ear. ***Myringotomy + aeration to middle ear*** - **Myringotomy** involves creating a small incision in the eardrum to drain fluid, and inserting a **grommet (ventilation tube)** to aerate the middle ear, which is the primary treatment for persistent glue ear (otitis media with effusion). - This procedure aims to restore ventilation to the middle ear, allowing trapped fluid to drain and preventing recurrent fluid accumulation, which improves hearing. *Temporal bone resection* - This is a major surgical procedure involving the removal of part of the temporal bone, typically reserved for extensive **malignant tumors** or severe infections, and is not indicated for glue ear. - It carries significant risks and is disproportionate to the treatment of a benign condition like glue ear. *Tonsillectomy & adenoidectomy* - While **adenoidectomy** can sometimes be performed in conjunction with grommet insertion if enlarged adenoids contribute to eustachian tube dysfunction, it is not the **primary treatment** for glue ear itself. - **Tonsillectomy** is generally performed for recurrent tonsillitis and has no direct role in treating glue ear. *Radical Mastoidectomy* - This is a highly invasive surgical procedure involving the removal of the mastoid air cells and part of the external auditory canal, typically performed for severe **cholesteatoma** or chronic mastoiditis. - It is an extensive and risky operation that is not appropriate for the management of glue ear, which is a much milder condition.

Q: Most common cause of sensorineural hearing loss (SNHL)

Presbycusis. ***Presbycusis*** - **Presbycusis**, or age-related hearing loss, is the most common cause of **sensorineural hearing loss (SNHL)**, affecting a significant portion of the elderly population. - It typically results from **degenerative changes** in the inner ear, specifically the hair cells and nerve fibers, leading to a gradual, symmetrical, high-frequency SNHL. *Labyrinthitis* - **Labyrinthitis** is an inflammation of the inner ear that can cause sudden SNHL, often accompanied by **vertigo** and **tinnitus**. - While it causes SNHL, it is an acute condition and not the most common overall cause, especially when considering the prevalence of age-related hearing loss. *Meniere's disease* - **Meniere's disease** is characterized by recurrent episodes of **vertigo, fluctuating low-frequency SNHL, tinnitus**, and aural fullness. - It is a specific condition causing SNHL, but its prevalence is much lower than presbycusis, making it a less common overall cause. *Vestibular Schwannoma* - A **vestibular schwannoma** (acoustic neuroma) is a benign tumor that arises from the Schwann cells of the **vestibulocochlear nerve**. - It can cause **progressive unilateral SNHL**, tinnitus, and balance issues, but it is a relatively rare condition compared to presbycusis.

Q: Cold water is not used for ear cleaning because

Caloric stimulation caused by cold water. ***Caloric stimulation caused by cold water*** - Irrigating the ear canal with **cold water** causes significant **caloric stimulation** of the vestibular system. - This can induce **vertigo**, **nausea**, and **vomiting** due to the temperature difference stimulating the semicircular canals. *Damage to tympanic membrane* - While excessive pressure from irrigation can potentially damage the **tympanic membrane**, the temperature of the water itself is not the primary factor for this risk. - Damage is more related to the **force of irrigation** and pre-existing membrane integrity, not cold temperature. *It will cause infection* - The temperature of the water used for irrigation does not directly determine the risk of infection. - **Infection risk** is primarily associated with using unsterile water or introducing bacteria into a compromised ear canal, regardless of water temperature. *It will make the wax hard* - Earwax, or **cerumen**, is softened by water irrigation, not hardened. - **Warm water** is typically preferred because it aids in softening the wax more effectively and comfortably than cold water.

Q: Tobey-Ayer test is done for:

Lateral sinus thrombosis. ***Lateral sinus thrombosis*** - The **Tobey-Ayer test** is used to detect **lateral (transverse) sinus thrombosis**, a serious complication of otogenic infections. - The test involves **lumbar puncture with CSF manometry** while sequentially compressing each **internal jugular vein**. - In a normal response, compression of either jugular vein causes a **rapid rise in CSF pressure** (within 10 seconds) due to venous obstruction, followed by rapid fall on release. - In **lateral sinus thrombosis**, compression of the jugular vein on the **affected side** produces **no rise or delayed/sluggish rise** in CSF pressure, indicating obstruction of venous drainage. - This is distinct from the Queckenstedt-Stookey test, which tests for spinal subarachnoid block. *Ketosis* - **Ketosis** is a metabolic state with elevated **ketone bodies** in blood, detected by urine dipsticks or blood ketone meters. - It has no relation to the Tobey-Ayer test or ENT pathology. *Acantholysis* - **Acantholysis** is loss of intercellular connections between **keratinocytes**, seen in blistering skin diseases like Pemphigus. - It is a histological dermatological finding, completely unrelated to neurological or ENT examination. *Hemoglobinuria* - **Hemoglobinuria** is the presence of free **hemoglobin** in urine due to intravascular hemolysis. - It is detected by urinalysis and has no connection to CSF manometry or lateral sinus assessment.

Q: Most common cause of facial nerve palsy:

Idiopathic Bell's palsy. ***Idiopathic Bell's palsy*** - **Bell's palsy** is the most common cause of **facial nerve palsy**, accounting for approximately 60-75% of cases. - It is an **idiopathic** condition, meaning its exact cause is unknown, although it is often linked to viral infections (e.g., herpes simplex virus). [1] *Mastoid surgery* - **Iatrogenic facial nerve injury** during mastoidectomy is a known complication, but it is a relatively rare cause of facial nerve palsy. - While it can cause significant palsy, the incidence is low compared to Bell's palsy. *Herpes zoster oticus* - This condition, also known as **Ramsay Hunt syndrome**, is a cause of facial nerve palsy associated with a **vesicular rash** (zoster) in the ear canal or on the face. - While it is a significant cause of viral-induced facial palsy, it is less common than idiopathic Bell's palsy. *Chronic suppurative Otitis media* - **Chronic otitis media** can, in rare cases, lead to facial nerve palsy due to persistent inflammation spreading to the facial nerve. [2] - This is a less common etiology than Bell's palsy and would typically present with a history of recurrent ear discharge and hearing loss.

Q: Most common cause of syndromic deafness is:

Waardenburg syndrome. **Waardenburg syndrome** - This is the **most common cause of syndromic deafness**, characterized by hearing loss combined with pigmentary anomalies. - Key features include congenital sensorineural hearing loss, heterochromia iridum (different colored eyes), a white forelock, and premature graying of hair. *Pendred syndrome* - This syndrome is the **second most common cause of syndromic deafness** and is associated with goiter (enlarged thyroid gland). - It results from mutations in the **SLC26A4 gene** and is characterized by sensorineural hearing loss and inner ear malformations (Mondini dysplasia). *Usher syndrome* - This is the **most common cause of combined deafness and blindness**, affecting both hearing and vision. - It involves sensorineural hearing loss and progressive **retinitis pigmentosa**, leading to night blindness and eventual vision loss. *All of the options* - While all listed syndromes cause syndromic deafness, Waardenburg syndrome is specifically identified as the **most common single cause**. - Therefore, choosing "all of the options" would be incorrect as it doesn't pinpoint the *most common* cause.

Q: Gelle's test is for:

Otosclerosis. ***Otosclerosis*** - **Gelle's test** is specifically designed to detect **otosclerosis**, a condition characterized by abnormal bone growth in the middle ear. - In otosclerosis, the **stapes footplate** becomes fixed, leading to a negative Gelle's test where sound perception does not change with pressure alterations in the external auditory canal. *NIHL* - **Noise-induced hearing loss (NIHL)** is a type of **sensorineural hearing loss** caused by prolonged exposure to loud noise. - Diagnostic relies on **audiometry** showing a characteristic notch at 4 kHz, and not Gelle's test. *Sensorineural deafness* - **Sensorineural deafness** affects the **cochlea or auditory nerve**, and is not specifically identified by Gelle's test. - While otosclerosis can lead to a mixed or sensorineural component over time, Gelle's test primarily assesses the **mobility of the ossicular chain**. *None of the options* - This option is incorrect because Gelle's test is a recognized diagnostic tool, particularly for **otosclerosis**. - Its utility is in determining changes in **bone conduction** with altered middle ear pressure.

Question 1

A patient presents with ear discharge. The CT image is shown below. Based on the clinical presentation and imaging, what is the most likely diagnosis?

Accepted Answer

Temporal lobe abscess

Answer

Extradural abscess

Answer

Cerebellar abscess

Answer

Meningitis

Question 2

A patient with a history of chronic ear infection now presents with manifestations, including headache and vomiting. A CT brain image is shown. What is the most probable diagnosis?

Accepted Answer

Temporal lobe Abscess

Answer

Meningitis

Answer

Extradural Abscess

Answer

Cerebral Abscess

Question 3

A 72-year-old man presents to his primary care physician with progressively worsening hearing loss. He states that his trouble with hearing began approximately 7-8 years ago. He is able to hear when someone is speaking to him; however, he has difficulty with understanding what is being said, especially when there is background noise. In addition to his current symptoms, he reports a steady ringing in both ears, and at times experiences dizziness. Medical history is significant for three prior episodes of acute otitis media. Family history is notable for his father being diagnosed with cholesteatoma. His temperature is 98.6°F (37°C), blood pressure is 138/88 mmHg, pulse is 74/min, and respirations are 13/min. On physical exam, when a tuning fork is placed in the middle of the patient's forehead, sound is appreciated equally on both ears. When a tuning fork is placed by the external auditory canal and subsequently on the mastoid process, air conduction is greater than bone conduction. Which of the following is most likely the cause of this patient's symptoms?

Accepted Answer

Cochlear hair cell degeneration

Answer

Stapedial abnormal bone growth

Answer

Endolymphatic hydrops

Answer

Accumulation of desquamated keratin debris

Question 4

Mainstay of treatment of glue ear -

Accepted Answer

Myringotomy + aeration to middle ear

Answer

Temporal bone resection

Answer

Tonsillectomy & adenoidectomy

Answer

Radical Mastoidectomy

Question 5

Most common cause of sensorineural hearing loss (SNHL)

Accepted Answer

Presbycusis

Answer

Labyrinthitis

Answer

Meniere's disease

Answer

Vestibular Schwannoma

Question 6

Cold water is not used for ear cleaning because

Accepted Answer

Caloric stimulation caused by cold water

Answer

Damage to tympanic membrane

Answer

It will cause infection

Answer

It will make the wax hard

Question 7

Tobey-Ayer test is done for:

Accepted Answer

Lateral sinus thrombosis

Answer

Ketosis

Answer

Acantholysis

Answer

Hemoglobinuria

Question 8

Most common cause of facial nerve palsy:

Accepted Answer

Idiopathic Bell's palsy

Answer

Mastoid surgery

Answer

Herpes zoster oticus

Answer

Chronic suppurative Otitis media

Question 9

Most common cause of syndromic deafness is:

Accepted Answer

Waardenburg syndrome

Answer

Pendred syndrome

Answer

Usher syndrome

Answer

All of the options

Question 10

Gelle's test is for:

Accepted Answer

Otosclerosis

Answer

NIHL

Answer

Sensorineural deafness

Answer

None of the options

Diseases of the Ear — MCQs

Diseases of the Ear — MCQs

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