Diseases of the Ear Practice Questions

Q: A 35-year-old patient presents with hearing loss and discomfort in the right ear. Examination reveals keratin accumulation in the ear canal. What is the most likely diagnosis?

Keratosis obturans. ***Keratosis obturans*** - This condition is characterized by an **accumulation of desquamated keratin** and epithelial debris in the bony external auditory canal, leading to earache, conductive hearing loss, and sometimes widening of the ear canal. - The patient's presentation of **hearing loss**, **discomfort in the right ear**, and **keratin accumulation** aligns directly with the description of keratosis obturans. *Exostosis* - Exostoses are **bony growths** in the ear canal, often associated with cold water exposure. - While they can cause hearing loss and earwax impaction, they do not involve primary **keratin accumulation** as described. *Cerumen* - **Cerumen** is normal earwax, which is a mix of secretions and desquamated cells. - While excessive cerumen can cause hearing loss, the description of **keratin accumulation** suggests a more organized, dense plug than typical cerumen impaction. *Otitis externa* - **Otitis externa** is an inflammation or infection of the ear canal, presenting with pain, redness, swelling, and discharge. - While it can cause discomfort and sometimes lead to debris, the primary finding is **inflammation**, not specifically a large accumulation of keratin.

Q: Tobey-Ayer test and Crowe-Beck test are used for?

Lateral sinus thrombosis. ***Lateral sinus thrombosis*** - The **Tobey-Ayer test** and **Crowe-Beck test** are classical methods used to diagnose **lateral sinus thrombosis**. - These tests rely on observing changes in **cerebrospinal fluid (CSF) pressure** upon compression of the jugular veins, which will be altered in the presence of a thrombus. *Subarachnoid hemorrhage* - Diagnosed primarily by **CT scan of the head** and analysis of **CSF for xanthochromia**. - While CSF is involved, these specific tests are not used for its diagnosis. *Petrositis* - This is an inflammation of the **petrous apex** of the temporal bone, often diagnosed with **CT or MRI** imaging. - The Tobey-Ayer and Crowe-Beck tests are not relevant to its diagnosis. *Cerebral abscess* - A localized collection of pus within the brain, diagnosed with **contrast-enhanced CT or MRI** of the brain. - These specific tests are irrelevant for the diagnostic workup of a cerebral abscess.

Q: Which cancers can cause referred otalgia (referred pain in the ear)? Select the most comprehensive answer.

Cancer of the pharynx, oral cavity, and larynx. ***Cancer of the pharynx, oral cavity, and larynx*** - Cancers in these locations can cause **referred otalgia** due to shared innervation of the ear by cranial nerves that also supply these areas. - Specifically, the **glossopharyngeal nerve (IX)**, **vagus nerve (X)**, and **trigeminal nerve (V3)** are involved in both sensation from these head and neck regions and the ear. *Cancer of the pharynx* - While pharyngeal cancer can cause **referred otalgia** through cranial nerves IX and X, it is not the most comprehensive answer as other sites are also involved. - This option exclusively mentions the pharynx, missing other important anatomical locations that can also refer pain to the ear. *Cancer of the oral cavity* - Cancer here can cause **referred otalgia**, primarily through the **trigeminal nerve (V3)**, which innervates parts of the oral cavity and the ear. - However, similar to pharyngeal cancer, this option is not comprehensive as it omits other regions related to referred ear pain. *Cancer of the larynx* - Laryngeal cancer can cause **referred otalgia** via the **vagus nerve (X)**, specifically its superior laryngeal branch. - This option is also incomplete as it does not include cancers of the pharynx or oral cavity, which are equally important causes of referred ear pain.

Q: Tuberculous otitis media of the middle ear has all of the following except:-

Painful otorrhea is seen. ***Painful otorrhea is seen*** - **Tuberculous otitis media** is often characterized by **painless otorrhea**, making painful otorrhea an unlikely finding. - The absence of pain is attributed to the **insidious** and slow-growing nature of the infection, which often delays diagnosis. *Multiple perforations are seen* - **Multiple tympanic membrane perforations** are a classic sign of tuberculous otitis media, differentiating it from other chronic otitis media forms. - These perforations are often **small and non-healing**, contributing to persistent discharge. *Pale granulomas are seen* - The presence of **pale granulomas** in the middle ear is a histological hallmark of tuberculosis, reflecting the characteristic **caseating granulomatous inflammation**. - These granulomas can lead to **ossicular erosion** and subsequent conductive hearing loss. *ATT should be started* - **Anti-tubercular treatment (ATT)** is the definitive therapy for tuberculous otitis media, targeting the underlying Mycobacterium tuberculosis infection. - Early initiation of ATT is crucial to prevent further **destruction** of middle ear structures and hearing loss.

Q: A 50-year-old diabetic presents with facial palsy, ear pain, and vesicles in EAC. Best initial treatment is:

IV acyclovir. ***IV acyclovir*** - The constellation of **facial palsy**, **ear pain**, and **vesicles in the external auditory canal** (EAC) in a diabetic patient is highly suggestive of **Herpes Zoster Oticus** (Ramsay Hunt Syndrome). - Given the patient's age and diabetes (an immunocompromised state), **intravenous acyclovir** is the best initial treatment to achieve higher drug concentrations quickly and prevent complications such as permanent facial paralysis or postherpetic neuralgia [1]. *Antibiotics* - Antibiotics are indicated for **bacterial infections**, but Ramsay Hunt Syndrome is caused by **Varicella-Zoster virus reactivation**, not bacteria. - Using antibiotics would be ineffective and could contribute to **antibiotic resistance**. *Oral steroids* - While steroids like prednisone are often used in conjunction with antivirals for Ramsay Hunt Syndrome to reduce inflammation and improve outcomes, they are not the **primary initial treatment** as they do not address the viral cause directly. - Steroids alone, especially in an immunocompromised diabetic patient, could potentially worsen the viral infection. *Oral acyclovir* - **Oral acyclovir** is used for Ramsay Hunt Syndrome, but **intravenous administration** is preferred as the initial treatment in patients with severe symptoms, immunocompromised states (like diabetes), or extensive disease to ensure better bioavailability and faster viral suppression [1]. - Oral acyclovir might be considered for milder cases or as a follow-up after initial IV treatment, but its absorption and efficacy are often lower compared to IV.

Q: A 60-year-old diabetic presents with otalgia, otorrhea, and granulation tissue in EAC. Empiric treatment should include:

Anti-pseudomonal therapy IV. ***Anti-pseudomonal therapy IV*** - The constellation of **otalgia**, **otorrhea**, **granulation tissue in the external auditory canal (EAC)**, and **diabetes** in an elderly patient is highly suggestive of **necrotizing (malignant) otitis externa**. - This condition is almost exclusively caused by **Pseudomonas aeruginosa**, requiring prompt and aggressive systemic anti-pseudomonal antibiotic therapy. *Fluconazole* - **Fluconazole** is an antifungal medication, while necrotizing otitis externa is primarily a bacterial infection. - While fungal infections can occur in the ear, the classic presentation described strongly points to a bacterial etiology, specifically *Pseudomonas*. *Cloxacillin oral* - **Cloxacillin** is a penicillinase-resistant penicillin primarily active against staphylococcal and streptococcal infections. - It does not provide adequate coverage against **Pseudomonas aeruginosa**, the causative agent of necrotizing otitis externa, and an oral route is insufficient for this severe infection. *Ciprofloxacin with steroids* - Oral **ciprofloxacin** is commonly used for *Pseudomonas* infections, but the severity and potential for skull base osteomyelitis in necrotizing otitis externa typically necessitate **intravenous therapy** initially. - **Steroids** are generally contraindicated in active infections like necrotizing otitis externa as they can suppress the immune response and worsen the infection.

Q: A child presents with recurrent ear infections and conductive hearing loss. What is the most likely diagnosis?

Glue ear. ***Correct: Glue ear*** - **Glue ear** (otitis media with effusion - OME) is the **most common cause of conductive hearing loss in children** - Frequently develops after **recurrent episodes of acute otitis media**, with persistent middle ear effusion - The thick, glue-like fluid behind the tympanic membrane impairs ossicular movement, causing **conductive hearing loss** - Classic presentation: child with history of recurrent ear infections who develops persistent hearing impairment between acute episodes - Diagnosis confirmed by **tympanometry** showing flat type B curve and **otoscopy** revealing retracted tympanic membrane with fluid level or air bubbles *Incorrect: Chronic otitis media* - Implies **persistent tympanic membrane perforation** with chronic discharge (>6-12 weeks) - More severe, established pathology with potential complications like cholesteatoma - While it causes conductive hearing loss, it's **less common** than OME in typical pediatric presentations - Would expect to see persistent otorrhea and visible perforation on examination *Incorrect: Acute otitis media* - Characterized by **sudden onset** with acute symptoms: otalgia, fever, irritability, bulging red tympanic membrane - While recurrent episodes are common in children, the question describes ongoing conductive hearing loss, suggesting **persistent effusion** rather than isolated acute episodes - Each acute episode resolves, but may be followed by OME *Incorrect: Otitis externa* - **External ear canal** infection ("swimmer's ear"), not a middle ear problem - Presents with ear pain worsened by **tragal pressure** or pinna manipulation, canal edema, and discharge - Does **not cause conductive hearing loss** unless severe canal occlusion occurs - Not associated with recurrent middle ear infections

Q: Which of the following is not a feature of otosclerosis?

Vertigo. ***Vertigo*** - While some forms of **otosclerosis** can, in rare cases, lead to **vestibular symptoms**, significant or prominent **vertigo** is not a typical or defining feature due to the primary involvement of the ossicular chain and cochlear otic capsule. - **Otosclerosis** primarily causes conductive or mixed hearing loss by fixing the stapes in the oval window, which does not directly lead to **vertigo**. *Paracusis of Willis* - **Paracusis of Willis** is a hallmark symptom of **otosclerosis**, where the patient hears better in noisy environments. - This occurs because normal-hearing individuals raise their voices in noisy environments, which helps the otosclerotic patient hear more clearly. *Schwartz sign* - The **Schwartz sign** (flamingo pink blush behind the tympanic membrane) is a characteristic clinical finding in **otosclerosis**. - It indicates increased vascularity resulting from active otospongiosis within the bony labyrinth. *Progressive hearing loss* - **Progressive hearing loss**, initially conductive and later often mixed, is the most common and defining symptom of **otosclerosis**. - This is due to the gradual fixation of the stapes footplate in the oval window by abnormal bone growth.

Q: Which of the following signs is not associated with otitis media with effusion?

AD curve on tympanometry with conductive hearing loss. ***AD curve on tympanometry with conductive hearing loss*** - An **AD tympanogram** indicates a **hypercompliant tympanic membrane**, often seen in conditions like ossicular discontinuity or healed perforations, not otitis media with effusion. - In otitis media with effusion, the presence of fluid behind the eardrum causes a **conductive hearing loss** but typically presents with a **Type B tympanogram**. *Mostly resolves on its own* - Otitis media with effusion often **spontaneously resolves** within weeks to months without specific intervention. - This characteristic is a common feature rather than an absence, making it associated with the condition. *Mostly bilateral* - Otitis media with effusion frequently affects **both ears**, especially in younger children due to immature Eustachian tube function. - This is a common presentation, so it is associated with the diagnosis. *Type B tympanogram* - A **Type B tympanogram** indicates a flat or absent peak, signifying **reduced mobility of the tympanic membrane** due to fluid in the middle ear. - This is the classic tympanometric finding for otitis media with effusion, confirming its association.

Q: What is the mechanism by which otosclerosis leads to hearing loss?

causes conductive hearing loss due to stapes immobilization. ***Causes conductive hearing loss due to stapes immobilization*** - **Otosclerosis** involves abnormal bone remodeling in the otic capsule, primarily affecting the **stapes footplate** - This abnormal bone growth leads to **fixation of the stapes** in the oval window, preventing its normal vibratory motion and thus impairing sound transmission to the inner ear - Results in **conductive hearing loss** as the primary and most common presentation *Causes hearing loss due to recurrent ear infections* - This mechanism describes **otitis media**, particularly chronic forms, which can lead to hearing loss through fluid accumulation or ossicular chain damage - Otosclerosis is a primary bone disorder, not caused by or directly associated with recurrent ear infections *Causes sensorineural hearing loss by damaging the cochlea* - While some cases of otosclerosis can have a sensorineural component (**cochlear otosclerosis**), the primary and most common mechanism is conductive - Sensorineural hearing loss is typically due to damage to the hair cells in the cochlea or the auditory nerve, which is not the principal pathology in otosclerosis *Causes damage to the auditory nerve* - Damage to the **auditory nerve** results in **sensorineural hearing loss** and is seen in conditions like acoustic neuroma or auditory neuropathy - Otosclerosis primarily affects the mechanical transmission of sound through the middle ear ossicles, not the neural pathways

Question 1

A 35-year-old patient presents with hearing loss and discomfort in the right ear. Examination reveals keratin accumulation in the ear canal. What is the most likely diagnosis?

Accepted Answer

Keratosis obturans

Answer

Exostosis

Answer

Cerumen

Answer

Otitis externa

Question 2

Tobey-Ayer test and Crowe-Beck test are used for?

Accepted Answer

Lateral sinus thrombosis

Answer

Subarachnoid hemorrhage

Answer

Petrositis

Answer

Cerebral abscess

Question 3

Which cancers can cause referred otalgia (referred pain in the ear)? Select the most comprehensive answer.

Accepted Answer

Cancer of the pharynx, oral cavity, and larynx

Answer

Cancer of the pharynx

Answer

Cancer of the oral cavity

Answer

Cancer of the larynx

Question 4

Tuberculous otitis media of the middle ear has all of the following except:-

Accepted Answer

Painful otorrhea is seen

Answer

Multiple perforations are seen

Answer

Pale granulomas are seen

Answer

ATT should be started

Question 5

A 50-year-old diabetic presents with facial palsy, ear pain, and vesicles in EAC. Best initial treatment is:

Accepted Answer

IV acyclovir

Answer

Antibiotics

Answer

Oral steroids

Answer

Oral acyclovir

Question 6

A 60-year-old diabetic presents with otalgia, otorrhea, and granulation tissue in EAC. Empiric treatment should include:

Accepted Answer

Anti-pseudomonal therapy IV

Answer

Fluconazole

Answer

Cloxacillin oral

Answer

Ciprofloxacin with steroids

Question 7

A child presents with recurrent ear infections and conductive hearing loss. What is the most likely diagnosis?

Accepted Answer

Glue ear

Answer

Acute otitis media

Answer

Otitis externa

Answer

Chronic otitis media

Question 8

Which of the following is not a feature of otosclerosis?

Accepted Answer

Vertigo

Answer

Paracusis of Willis

Answer

Schwartz sign

Answer

Progressive hearing loss

Question 9

Which of the following signs is not associated with otitis media with effusion?

Accepted Answer

AD curve on tympanometry with conductive hearing loss

Answer

Mostly resolves on its own

Answer

Mostly bilateral

Answer

Type B tympanogram

Question 10

What is the mechanism by which otosclerosis leads to hearing loss?

Accepted Answer

causes conductive hearing loss due to stapes immobilization

Answer

causes hearing loss due to recurrent ear infections

Answer

causes sensorineural hearing loss by damaging the cochlea

Answer

causes damage to the auditory nerve

Diseases of the Ear — MCQs

Diseases of the Ear — MCQs

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