Diseases of the Ear — MCQs
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A 5-year-old boy has had repeated bouts of earache for 3 years. Each time on examination, the bouts have been accompanied by a red, bulging tympanic membrane, either unilaterally or bilaterally, sometimes with a small amount of yellowish exudate. Laboratory studies have included cultures of Staphylococcus aureus, Pseudomonas aeruginosa, and Moraxella catarrhalis. The most recent examination shows that the right tympanic membrane has perforated. The boy responds to antibiotic therapy. Which of the following complications is most likely to occur as a consequence of these events?
Fick's operation and Cody Tack's procedure are used for which condition?
A child presents with an ear infection with foul-smelling discharge. On further exploration, a small perforation is found in the pars flaccida of the tympanic membrane. What is the most appropriate next step in the management?
Ramsay Hunt syndrome: all are true EXCEPT?
Dehiscence of the anterior wall of the external auditory canal causes infection in the parotid gland via which anatomical structure?
What is the treatment of choice for unsafe CSOM with cholesteatoma and sensorineural deafness?
Myringotomy is indicated in which of the following conditions?
Mastoid infection which erodes through the outer cortex of bone results in what?
Which of the following is NOT true about hearing loss in otosclerosis?
A 70-year-old male presents with hearing loss and tinnitus. On examination, he was observed to have a conductive type of deafness and a dull tympanic membrane on the right side. Lymph nodal enlargement of 3 × 3 cm was noted in the posterior triangle of the neck. Tympanogram revealed a type B wave. What is the most likely diagnosis?
Diseases of the Ear Indian Medical PG Practice Questions and MCQs
Question 31: A 5-year-old boy has had repeated bouts of earache for 3 years. Each time on examination, the bouts have been accompanied by a red, bulging tympanic membrane, either unilaterally or bilaterally, sometimes with a small amount of yellowish exudate. Laboratory studies have included cultures of Staphylococcus aureus, Pseudomonas aeruginosa, and Moraxella catarrhalis. The most recent examination shows that the right tympanic membrane has perforated. The boy responds to antibiotic therapy. Which of the following complications is most likely to occur as a consequence of these events?
- A. Cholesteatoma (Correct Answer)
- B. Eosinophilic granuloma
- C. Labyrinthitis
- D. Otosclerosis
Explanation: **Explanation:** The clinical presentation describes recurrent bouts of **Acute Otitis Media (AOM)** and chronic middle ear inflammation. The key finding is the **perforation of the tympanic membrane** following repeated infections. **Why Cholesteatoma is the correct answer:** Recurrent middle ear infections and tympanic membrane perforations (especially marginal or attic types) can lead to the formation of an **Acquired Cholesteatoma**. This occurs via two primary mechanisms: 1. **Migration:** Squamous epithelium from the external auditory canal migrates through the perforation into the middle ear. 2. **Retraction:** Chronic Eustachian tube dysfunction leads to negative middle ear pressure, causing a retraction pocket (usually in the pars flaccida) that traps keratin debris. Over time, this keratinizing squamous epithelium expands and produces proteolytic enzymes that erode surrounding bone (ossicles, mastoid). **Why other options are incorrect:** * **Eosinophilic granuloma:** A localized form of Langerhans Cell Histiocytosis; it presents as a "punched-out" lytic bone lesion, not as a direct complication of recurrent pyogenic otitis media. * **Labyrinthitis:** While a potential complication of otitis media, it involves the inner ear (causing vertigo and sensorineural hearing loss). Cholesteatoma is a more direct and common structural consequence of chronic/recurrent perforation. * **Otosclerosis:** A genetic/idiopathic condition involving bony overgrowth of the stapes footplate, leading to conductive hearing loss. It is not caused by infection or inflammation. **NEET-PG High-Yield Pearls:** * **Cholesteatoma** is "skin in the wrong place." It is histologically characterized by keratinizing squamous epithelium. * **Hallmark sign:** A pearly white mass behind the tympanic membrane or in a retraction pocket. * **Bone erosion:** Mediated by osteoclast activation and cytokines (TNF-α, IL-1). * **Treatment:** Always surgical (Tympanomastoidectomy) because it is locally invasive and does not respond to medication.
Question 32: Fick's operation and Cody Tack's procedure are used for which condition?
- A. Otosclerosis
- B. Meniere's disease (Correct Answer)
- C. Atrophic rhinitis
- D. Benign positional vertigo
Explanation: **Explanation:** **Meniere’s Disease** is characterized by **endolymphatic hydrops**, where there is an excessive accumulation of endolymph in the inner ear. Surgical management is indicated when medical therapy fails. * **Fick’s Operation:** This involves creating a permanent opening (fenestration) in the footplate of the stapes to decompress the saccule. * **Cody’s Tack Procedure:** A modification of Fick's operation where a small stainless steel "tack" is driven through the stapes footplate. When the saccule distends due to hydrops, it strikes the tack and punctures itself, leading to automatic decompression. **Why other options are incorrect:** * **Otosclerosis:** Managed primarily via **Stapedotomy** or Stapedectomy. It involves bony overgrowth of the stapes footplate, not fluid pressure issues. * **Atrophic Rhinitis:** A nasal condition (not ear) managed by procedures like **Young’s operation** or Modified Young’s operation. * **Benign Paroxysmal Positional Vertigo (BPPV):** Caused by canalolithiasis/cupulolithiasis. It is managed by particle repositioning maneuvers (e.g., **Epley’s maneuver**) or, rarely, posterior semicircular canal occlusion. **High-Yield Clinical Pearls for NEET-PG:** * **Meniere’s Triad:** Episodic vertigo, sensorineural hearing loss (fluctuating, low-frequency), and tinnitus/aural fullness. * **Lermoyez Syndrome:** A variant of Meniere’s where hearing improves during a vertigo attack. * **Other Surgeries for Meniere’s:** Endolymphatic sac decompression (ESD), Vestibular nerve section, and Labyrinthectomy (destructive procedure). * **Medical Management:** Low salt diet, Betahistine, and diuretics.
Question 33: A child presents with an ear infection with foul-smelling discharge. On further exploration, a small perforation is found in the pars flaccida of the tympanic membrane. What is the most appropriate next step in the management?
- A. Topical antibiotics and decongestants for 4 weeks
- B. IV antibiotics and follow up after a month
- C. Tympanoplasty
- D. Tympanomastoid exploration (Correct Answer)
Explanation: ### Explanation **1. Why the Correct Answer is Right:** The clinical presentation of **foul-smelling discharge** and a **pars flaccida perforation** is a classic indicator of **Attico-antral type** of Chronic Suppurative Otitis Media (CSOM). This type is often associated with **cholesteatoma**, an epithelial-lined sac that produces osteolytic enzymes, leading to bone destruction and life-threatening intracranial complications. Because Attico-antral disease is "unsafe," the primary goal of management is the complete eradication of the disease and making the ear "safe." **Tympanomastoid exploration** (which may include a Modified Radical Mastoidectomy or Canal Wall Up/Down procedures) is the definitive treatment to remove the cholesteatoma and explore the mastoid air cell system. **2. Why the Incorrect Options are Wrong:** * **Options A & B:** Medical management (topical or IV antibiotics) may temporarily reduce the discharge by treating secondary infection, but it **cannot cure** a cholesteatoma. Delaying surgery increases the risk of complications like facial nerve palsy, labyrinthitis, or brain abscess. * **Option C:** Tympanoplasty is a reconstructive procedure aimed at closing a perforation in the pars tensa (Tubotympanic/Safe type). In Attico-antral disease, reconstruction is secondary to the mandatory exploration and clearance of the mastoid and attic. **3. Clinical Pearls for NEET-PG:** * **Pars Flaccida Perforation:** Pathognomonic for Attico-antral (Unsafe) CSOM. * **Foul Smell:** Suggests bone destruction (osteitis) or the presence of anaerobic organisms in a cholesteatoma. * **Marginal Perforation:** Another hallmark of unsafe CSOM, usually involving the posterosuperior quadrant. * **Investigation of Choice:** HRCT Temporal Bone (to assess the extent of bone erosion). * **Treatment Goal:** 1st: Safety (remove disease); 2nd: Dry ear; 3rd: Hearing restoration.
Question 34: Ramsay Hunt syndrome: all are true EXCEPT?
- A. VII Nerve is involved
- B. Facial muscles are involved
- C. Facial vesicles are seen (Correct Answer)
- D. Herpes zoster is the etiologic agent
Explanation: **Explanation:** Ramsay Hunt Syndrome (Herpes Zoster Oticus) is caused by the reactivation of the **Varicella Zoster Virus (VZV)** in the **geniculate ganglion** of the Facial Nerve (CN VII). **Why Option C is the correct answer (The Exception):** In Ramsay Hunt Syndrome, the characteristic herpetic vesicles are typically found in the **concha of the auricle, the external auditory canal, and sometimes the soft palate**. They are **not** typically described as "facial vesicles" (which would imply a distribution across the skin of the face, more common in Trigeminal nerve involvement). The classic presentation is a triad of ipsilateral facial paralysis, otalgia, and **vesicles in the ear/auditory canal.** **Analysis of other options:** * **Option A & B:** The syndrome involves the **VII Nerve (Facial Nerve)**. Since this nerve provides motor innervation to the muscles of facial expression, its involvement leads to lower motor neuron (LMN) type facial palsy, meaning **facial muscles** are indeed involved. * **Option D:** **Herpes zoster** (reactivated VZV) is the definitive etiologic agent. **NEET-PG High-Yield Pearls:** * **Nerves Involved:** Primarily CN VII, but CN VIII is often co-involved, leading to sensorineural hearing loss, vertigo, and tinnitus. * **Prognosis:** The facial paralysis in Ramsay Hunt Syndrome is generally more severe and has a poorer recovery rate compared to Bell’s Palsy. * **Treatment:** Combination of oral Acyclovir/Valacyclovir and systemic Steroids. * **Diagnosis:** Clinical; however, T1-weighted MRI with gadolinium may show enhancement of the geniculate ganglion and facial nerve.
Question 35: Dehiscence of the anterior wall of the external auditory canal causes infection in the parotid gland via which anatomical structure?
- A. Fissure of Santorini (Correct Answer)
- B. Notch of Rivinus
- C. Petrous fissure
- D. Retropharyngeal fissure
Explanation: ### Explanation The external auditory canal (EAC) consists of an outer cartilaginous part (1/3rd) and an inner bony part (2/3rd). The **Fissure of Santorini** (incisura terminalis) refers to the vertical deficiencies or gaps found in the **anterior wall of the cartilaginous EAC**. These fissures are filled with fibrous tissue but provide a potential anatomical pathway for the spread of infection or neoplasms between the EAC and the **parotid gland** or the infratemporal fossa. #### Analysis of Options: * **A. Fissure of Santorini (Correct):** These are natural defects in the cartilaginous part of the EAC. They allow infections (like malignant otitis externa) to spread from the ear to the parotid gland and vice versa. * **B. Notch of Rivinus:** This is a deficiency in the **bony** part of the EAC (specifically the tympanic sulcus) at its superior aspect. It is the site where the pars flaccida (Shrapnell’s membrane) of the tympanic membrane is attached. It does not communicate with the parotid. * **C. Petrous fissure (Petrotympanic fissure):** Also known as the Glaserian fissure, it houses the chorda tympani nerve. While it is a bony landmark, it is not the primary route for parotid-EAC infection spread. * **D. Retropharyngeal fissure:** This is not a standard anatomical term related to the EAC; the retropharyngeal space is located behind the pharynx. #### High-Yield Clinical Pearls for NEET-PG: * **Malignant Otitis Externa:** The Fissure of Santorini is the classic route through which *Pseudomonas* infection spreads from the EAC to the parotid and skull base. * **Foramen of Huschke:** This is a deficiency in the **anteroinferior bony wall** of the EAC (present in children, usually closes by age 5). If persistent, it can also facilitate the spread of infection between the EAC and the parotid/TMJ. * **Cartilaginous vs. Bony:** Remember, Santorini = Cartilaginous; Rivinus/Huschke = Bony.
Question 36: What is the treatment of choice for unsafe CSOM with cholesteatoma and sensorineural deafness?
- A. Simple mastoidectomy
- B. Modified radical mastoidectomy (Correct Answer)
- C. Radical mastoidectomy
- D. Tympanoplasty
Explanation: **Explanation:** The primary goal in the management of **Unsafe Chronic Suppurative Otitis Media (CSOM)** with cholesteatoma is to create a "permanent, safe, and dry ear" by removing all disease. **1. Why Modified Radical Mastoidectomy (MRM) is the Correct Choice:** MRM is the standard treatment for unsafe CSOM. It involves removing the disease (cholesteatoma/granulations) from the attic and antrum while **preserving the remnants of the tympanic membrane and ossicles** (if present). Even in the presence of sensorineural deafness, MRM is preferred over Radical Mastoidectomy because it maintains the anatomical integrity of the middle ear and allows for future hearing rehabilitation (like a bone-anchored hearing aid) while ensuring the ear is safe. **2. Why other options are incorrect:** * **Simple Mastoidectomy:** This is used for **Acute Mastoiditis** or ASOM complications. It removes air cells without disturbing the posterior meatal wall or middle ear, making it inadequate for cholesteatoma. * **Radical Mastoidectomy:** This involves the total removal of the tympanic membrane, ossicles (except stapes), and closure of the Eustachian tube, converting the middle ear and mastoid into a single cavity. It is reserved for specific cases like **malignancy** or **unreconstructable Eustachian tube dysfunction**, not routine unsafe CSOM. * **Tympanoplasty:** This is the treatment of choice for **Safe (Tubotympanic) CSOM**. It focuses on reconstructing the hearing mechanism but does not address the mastoid disease seen in unsafe CSOM. **High-Yield Clinical Pearls for NEET-PG:** * **Goal Hierarchy in Unsafe CSOM:** 1. Safety (Remove disease) → 2. Dry Ear → 3. Hearing Preservation. * **Canal Wall Down (CWD) Procedure:** MRM is a CWD procedure where the posterior meatal wall is removed to exteriorize the disease. * **Cholesteatoma Hallmark:** Bone erosion due to osteoclast activation and enzymes like acid phosphatase.
Question 37: Myringotomy is indicated in which of the following conditions?
- A. Coalescent mastoiditis
- B. Cholesteatoma
- C. Acute suppurative otitis media (ASOM) (Correct Answer)
- D. External otitis media
Explanation: **Explanation:** **Myringotomy** is a surgical procedure involving a small incision in the tympanic membrane to relieve pressure or drain fluid from the middle ear. **Why ASOM is the correct answer:** In **Acute Suppurative Otitis Media (ASOM)**, the middle ear space fills with purulent exudate. Myringotomy is specifically indicated during the **stage of suppuration** when the eardrum is bulging and the patient experiences severe pain, high fever, or impending complications. It serves to provide immediate pain relief, facilitate drainage, and prevent a jagged, spontaneous rupture which heals poorly compared to a clean surgical incision. **Analysis of Incorrect Options:** * **Coalescent Mastoiditis:** This is a complication of ASOM where the bony septa of the mastoid air cells are destroyed. The definitive treatment is a **Cortical Mastoidectomy**, not just a myringotomy. * **Cholesteatoma:** This involves keratinized squamous epithelium in the middle ear/mastoid (bone-eroding). Treatment requires surgical removal via **Canal Wall Up or Down Mastoidectomy**. * **External Otitis Media:** This is an infection of the external auditory canal (skin). Since the pathology is lateral to the tympanic membrane, an incision into the middle ear is contraindicated and unnecessary. **High-Yield Clinical Pearls for NEET-PG:** * **Incision Site:** Usually performed in the **antero-inferior quadrant** to avoid injury to the ossicles (incus/stapes) and the chorda tympani nerve. * **ASOM vs. SOM:** In ASOM, the incision is circular (to keep it open for drainage); in Serous Otitis Media (SOM), a radial incision is made (often for Grommet insertion). * **Indication:** Myringotomy is also indicated in ASOM if the patient develops facial nerve palsy or labyrinthitis.
Question 38: Mastoid infection which erodes through the outer cortex of bone results in what?
- A. Sub-periosteal abscess (Correct Answer)
- B. Epidural abscess
- C. Perichondritis
- D. Lateral sinus thrombosis
Explanation: ### Explanation **1. Why Sub-periosteal Abscess is Correct:** The mastoid bone is bounded laterally by the **outer cortex** and medially by the inner table (which separates it from the brain). In acute coalescent mastoiditis, pus accumulates under pressure within the mastoid air cells. When this infection erodes through the **outer cortex**, the pus collects between the bone and the overlying periosteum, forming a **sub-periosteal abscess**. The most common site for this is the "Post-auricular abscess," which displaces the pinna forwards, downwards, and outwards. **2. Why the Other Options are Incorrect:** * **B. Epidural Abscess:** This occurs when the infection erodes through the **inner table** (posterior or middle cranial fossa plate) rather than the outer cortex. It is an intracranial complication where pus collects between the bone and the dura mater. * **C. Perichondritis:** This is an infection of the cartilage of the pinna, usually following trauma or infected hematoma. It does not originate from the mastoid bone cortex. * **D. Lateral Sinus Thrombosis:** This is a vascular complication caused by the erosion of the **posterior fossa plate** (inner table), leading to inflammation and thrombus formation within the sigmoid/lateral sinus. **3. NEET-PG High-Yield Pearls:** * **Bezold’s Abscess:** Pus erodes through the mastoid tip into the **sternocleidomastoid** sheath (presents as a neck swelling). * **Luc’s Abscess:** Pus erodes through the **meatal wall** into the external auditory canal. * **Citelli’s Abscess:** Pus erodes through the mastoid tip into the **digastric fossa**. * **Zygomatic Abscess:** Pus erodes into the root of the zygoma, causing swelling over the cheek. * **Radiology:** The "Clouding of mastoid air cells" with loss of bony trabeculae (coalescence) is the hallmark of surgical mastoiditis on CT.
Question 39: Which of the following is NOT true about hearing loss in otosclerosis?
- A. Common in males older than 40 years (Correct Answer)
- B. Associated with vertigo
- C. Characterized by Paracusis Willisii
- D. May present with Schwartz sign
Explanation: **Explanation:** Otosclerosis is a primary metabolic bone disease of the otic capsule characterized by the replacement of normal bone with vascular spongy bone, leading to stapedial fixation and conductive hearing loss. **Why Option A is the correct answer (False Statement):** Otosclerosis typically presents in **young adults (20–30 years)** and is significantly more common in **females** (Ratio 2:1). The condition is often exacerbated by hormonal changes such as pregnancy or puberty. Therefore, the statement that it is common in males older than 40 is epidemiologically incorrect. **Analysis of other options:** * **Option B (Associated with vertigo):** While primarily a hearing disorder, "Cochlear Otosclerosis" or "Otospongiosis" can involve the vestibular system, leading to balance disturbances or vertigo in a subset of patients. * **Option C (Paracusis Willisii):** This is a classic clinical feature where the patient hears better in noisy environments. This occurs because background noise causes others to speak louder, and the patient’s conductive loss filters out the low-frequency ambient noise. * **Option D (Schwartz sign):** Also known as the "Flamingo Flush," this is a reddish hue seen through the tympanic membrane due to increased vascularity of the promontory during the active phase of the disease (Otospongiosis). **NEET-PG High-Yield Pearls:** * **Carhart’s Notch:** A characteristic dip in the bone conduction audiogram at **2000 Hz**. * **Gelle’s Test:** Negative (indicates stapes fixation). * **Tympanometry:** Typically shows an **As type** curve (reduced compliance). * **Treatment of Choice:** Stapedotomy (most common) or Stapedectomy. * **Medical Management:** Sodium Fluoride (used to mature active foci).
Question 40: A 70-year-old male presents with hearing loss and tinnitus. On examination, he was observed to have a conductive type of deafness and a dull tympanic membrane on the right side. Lymph nodal enlargement of 3 × 3 cm was noted in the posterior triangle of the neck. Tympanogram revealed a type B wave. What is the most likely diagnosis?
- A. Middle ear tumor
- B. Nasopharyngeal malignancy (Correct Answer)
- C. Acoustic neuroma
- D. Tuberculosis of the middle ear
Explanation: ### Explanation The clinical presentation of a **70-year-old male** with unilateral conductive hearing loss, a dull tympanic membrane, and a **Type B tympanogram** (indicating fluid in the middle ear) strongly suggests **Otitis Media with Effusion (OME)**. In an elderly patient, unilateral OME is considered a **nasopharyngeal malignancy** until proven otherwise. **Why Nasopharyngeal Malignancy is correct:** The tumor typically arises in the **Fossa of Rosenmüller**, where it obstructs the opening of the **Eustachian tube**. This leads to negative middle ear pressure and subsequent fluid accumulation (serous otitis media). The presence of a **3 × 3 cm lymph node in the posterior triangle** (Level V) is a classic sign, as nasopharyngeal carcinoma frequently metastasizes to the cervical lymph nodes (often the presenting symptom). **Why other options are incorrect:** * **Middle ear tumor:** While Glomus tumors can cause hearing loss, they typically present with a "pulsatile" tinnitus and a "rising sun" appearance behind the drum, rather than isolated posterior triangle lymphadenopathy. * **Acoustic neuroma:** This is a tumor of the 8th cranial nerve presenting with **Sensorineural Hearing Loss (SNHL)** and a Type A tympanogram, not conductive loss with fluid. * **Tuberculosis of the middle ear:** Characterized by multiple perforations, painless "cheesy" otorrhea, and profound hearing loss; it is less common in this age group without systemic symptoms. ### High-Yield Clinical Pearls for NEET-PG: * **Trotter’s Triad (for Nasopharyngeal Ca):** 1. Conductive hearing loss (due to OME), 2. Ipsilateral facial/temporoparietal pain (Trigeminal neuralgia), 3. Palatal paralysis (Ipsilateral). * **Diagnostic Rule:** Any adult with unilateral serous otitis media must undergo **diagnostic nasal endoscopy (DNE)** to visualize the nasopharynx. * **Lymph Nodes:** The "Node of Rouviere" (lateral retropharyngeal node) is often the first to be involved, but Level II and V nodes are common clinical findings.
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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