Diseases of the Ear Practice Questions

Q: Which of the following is NOT true about Malignant otitis externa?

Completely monitored with TC99 scan till recovery. **Explanation:** Malignant Otitis Externa (MOE), also known as **Necrotizing Otitis Externa**, is a life-threatening progressive infection of the external auditory canal that spreads to the skull base (osteomyelitis). **Why Option B is the correct (False) statement:** Technetium-99m (Tc99) bone scans are highly sensitive for detecting early bone involvement because they pick up increased osteoblastic activity. However, Tc99 scans **remain positive for several months** even after the infection has resolved (due to ongoing bone remodeling). Therefore, they cannot be used to monitor treatment response or confirm recovery. The investigation of choice for monitoring resolution and "cooling down" of the disease is the **Gallium-67 scan**, which tracks active inflammation/leukocyte activity. **Analysis of other options:** * **Option A:** **Pseudomonas aeruginosa** is the causative organism in more than 95% of cases. It is typically seen in elderly diabetic patients or immunocompromised individuals. * **Option C:** It is synonymous with **Necrotizing Otitis Externa** because the infection causes extensive necrosis of soft tissue, cartilage, and bone. * **Option D:** As the disease spreads to the skull base, it can involve cranial nerves. The **Facial nerve (CN VII)** is the most commonly affected nerve (at the stylomastoid foramen), leading to facial muscle paralysis. **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. * **Diagnosis:** CT scan is best for assessing the extent of bone erosion; MRI is superior for soft tissue/dural involvement. * **Treatment:** Long-term systemic IV antipseudomonal antibiotics (e.g., Ciprofloxacin, Ceftazidime) and strict glycemic control.

Q: The fistula test stimulates which structure?

Lateral semicircular canal. ### Explanation **1. Why the Lateral Semicircular Canal (LSCC) is Correct:** The fistula test is performed by applying positive or negative pressure to the external auditory canal (using a Siegel’s speculum or tragal pressure). In the presence of a **labyrinthine fistula**—most commonly caused by a cholesteatoma eroding the bony labyrinth—this pressure is transmitted directly to the endolymph. Because the **Lateral Semicircular Canal** is the most lateral and superficial part of the vestibular system, it is the most frequent site of erosion (85–90% of cases). The pressure change induces endolymph movement, stimulating the crista ampullaris, which results in vertigo and nystagmus (Hennebert’s sign). **2. Why the Other Options are Incorrect:** * **Posterior and Anterior Semicircular Canals:** While these are part of the vestibular system, they are located deeper within the petrous temporal bone and are rarely the primary site of erosion in chronic suppurative otitis media (CSOM). * **Cochlea:** The cochlea is responsible for hearing (auditory function). While a fistula can rarely involve the promontory, the fistula test specifically looks for a vestibular response (nystagmus/vertigo), which is a function of the semicircular canals. **3. Clinical Pearls for NEET-PG:** * **Hennebert’s Sign:** A "false positive" fistula test (nystagmus without a bony fistula). It is classically seen in **Meniere’s disease** (due to adhesions between the stapes footplate and saccule) and **Congenital Syphilis**. * **False Negative Test:** May occur if the fistula is plugged by cholesteatoma or granulation tissue, or if the labyrinth is "dead" (non-functional). * **Management:** A positive fistula test in the context of CSOM is an absolute indication for surgery (Mastoidectomy) to prevent labyrinthitis or intracranial complications.

Q: A patient with a history of right ear discharge undergoes mastoidectomy. Postoperatively, the patient presents with vertigo and deafness. What is the most likely diagnosis?

Labyrinthitis. **Explanation:** The clinical presentation of **vertigo** and **deafness** following mastoid surgery in a patient with chronic ear discharge is a classic indicator of **Labyrinthitis**. **1. Why Labyrinthitis is correct:** The inner ear (labyrinth) is in close anatomical proximity to the middle ear and mastoid. During surgery for chronic otitis media (especially if a cholesteatoma is present), the protective bony covering of the labyrinth (most commonly the lateral semicircular canal) may be breached or eroded. This allows inflammatory mediators or infection to enter the inner ear, leading to **suppurative labyrinthitis**. This results in the "dead ear" phenomenon—characterized by a combination of **vestibular symptoms (vertigo)** and **cochlear symptoms (sensorineural hearing loss/deafness)**. **2. Why other options are incorrect:** * **Thrombophlebitis (Sigmoid Sinus):** Presents with "picket-fence" fever, headache, and signs of increased intracranial pressure, but not typically sudden deafness. * **Temporal Lobe Abscess:** An intracranial complication presenting with headache, vomiting, seizures, and focal neurological deficits (like nominal aphasia), rather than primary inner ear symptoms. * **Mastoiditis:** This is an infection of the mastoid air cells themselves. While it is the reason for the surgery, it does not explain the acute onset of postoperative vertigo and deafness unless it progresses to labyrinthitis. **NEET-PG High-Yield Pearls:** * **Most common site of fistula:** Lateral Semicircular Canal (LSCC). * **Fistula Test:** Positive when pressure changes in the canal induce vertigo/nystagmus; it becomes negative once the ear is "dead" (Labyrinthitis). * **Management:** Labyrinthitis is a surgical emergency if caused by acute infection; it requires high-dose antibiotics and sometimes surgical drainage.

Q: Which of the following statements are true about otitis media with effusion in a child?

A Type B tympanogram is observed.. **Explanation:** **Otitis Media with Effusion (OME)**, also known as "Glue Ear," is characterized by the accumulation of non-purulent fluid in the middle ear cleft without signs of acute infection. 1. **Why Option B is Correct:** Tympanometry is the gold standard for diagnosing OME. A **Type B (Flat) tympanogram** is observed because the fluid behind the tympanic membrane increases its mass and stiffness, resulting in restricted mobility. This leads to a lack of a compliance peak, regardless of the pressure changes applied. 2. **Why the Other Options are Incorrect:** * **Option A:** Immediate myringotomy is not indicated. The initial management is **watchful waiting** for 3 months, as many cases resolve spontaneously. Surgery (myringotomy with grommet insertion) is reserved for persistent or bilateral cases with significant hearing loss. * **Option C:** While the fluid is non-purulent, it is **not always sterile**. Studies have shown that bacteria (like *H. influenzae* or *S. pneumoniae*) or biofilms are present in approximately 30-50% of cases, though they do not cause acute symptoms. * **Option D:** OME is the most common cause of **conductive** hearing loss in children, but it is not the most common cause of "deafness" (a term usually implying profound sensorineural loss) in daycare settings. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause:** Eustachian tube dysfunction (often due to adenoid hypertrophy in children). * **Otoscopy findings:** Dull/opaque tympanic membrane, retracted drum, or presence of air bubbles/fluid levels. * **Hearing loss:** Conductive type, usually 20–40 dB. * **Treatment of choice (Surgical):** Myringotomy with **Grommet (Ventilation tube)** insertion, typically in the antero-inferior quadrant. * **Rule of thumb:** In an adult with unilateral OME, always rule out **Nasopharyngeal Carcinoma**.

Q: What is the appropriate treatment for an acute stable hematoma of the pinna of the ear?

Incision, drainage, and pressure bandage. **Explanation:** The primary goal in managing an auricular hematoma is to evacuate the blood collection and prevent its recurrence. The pinna's cartilage relies on the overlying perichondrium for its blood supply. A hematoma creates a space between these layers, leading to ischemic necrosis of the cartilage if not treated promptly. **Why Option D is Correct:** **Incision and Drainage (I&D)** followed by a **pressure bandage** is the gold standard. I&D ensures complete evacuation of the clot (which may be too viscous for a needle). The pressure bandage is crucial because it obliterates the "dead space," preventing the re-accumulation of blood and ensuring the perichondrium re-adheres to the cartilage. **Why Other Options are Incorrect:** * **Option A:** Ice packs may reduce swelling but will not remove the existing extravasated blood. Antibiotics are supportive but do not address the mechanical problem. * **Option B:** Excision implies removing tissue; only the blood collection needs removal, not the ear tissue itself. * **Option C:** Needle aspiration is associated with a high rate of recurrence (up to 70%) because the small bore cannot evacuate organized clots and the space often refills immediately without a formal pressure dressing. **High-Yield Clinical Pearls for NEET-PG:** * **Cauliflower Ear:** The classic complication of untreated or inadequately treated hematoma, where fibrocartilage overgrowth leads to permanent deformity. * **Timeframe:** Treatment should ideally occur within **48–72 hours** of injury. * **Incision Site:** Usually made along the natural curvature of the helical rim to minimize scarring. * **Antibiotics:** Post-procedure antibiotics should cover *Pseudomonas aeruginosa* (e.g., Fluoroquinolones), as it is the most common cause of secondary perichondritis.

Q: Hyperacusis is seen in all of the following conditions except:

Otosclerosis. **Explanation:** **Hyperacusis** is a condition characterized by an increased sensitivity or intolerance to ordinary environmental sounds. It typically occurs due to the loss of the protective **stapedial reflex** (mediated by the facial nerve) or recruitment phenomena in cochlear disorders. **Why Otosclerosis is the Correct Answer:** In **Otosclerosis**, there is fixation of the stapes footplate in the oval window. This leads to **Conductive Hearing Loss (CHL)**. Patients with CHL actually experience the opposite of hyperacusis; they often perceive their own voice as louder (autophony) and find noisy environments helpful for hearing (Paracusis Willisii). Since the stapes is fixed, the ear is "protected" from sound transmission, making hyperacusis clinically inconsistent with this diagnosis. **Analysis of Incorrect Options:** * **Exposure to loud sounds:** Acute acoustic trauma can damage the hair cells and disrupt the auditory processing pathway, leading to temporary or permanent hyperacusis. * **Meniere’s disease:** This is a classic cause of **Recruitment**. In recruitment, the ear abnormally perceives a small increase in physical sound intensity as a large increase in loudness, leading to intolerance of loud sounds despite having hearing loss. * **Severe head injury:** Trauma can result in a perilymph fistula, facial nerve paralysis (loss of stapedial reflex), or central auditory pathway damage, all of which are known triggers for hyperacusis. **NEET-PG High-Yield Pearls:** * **Facial Nerve Palsy:** Hyperacusis occurs if the nerve to the stapedius (a branch of CN VII) is involved, as the stapedius muscle can no longer dampen loud sounds. * **Recruitment vs. Hyperacusis:** Recruitment is specific to cochlear lesions (e.g., Meniere’s), whereas hyperacusis is a broader term for sound intolerance. * **Bell’s Palsy:** Hyperacusis is a key prognostic clinical sign indicating a lesion proximal to the middle ear.

Q: What is the characteristic of glue ear?

Painless. **Explanation:** **Glue Ear**, clinically known as **Otitis Media with Effusion (OME)**, is characterized by the accumulation of non-purulent, mucoid fluid in the middle ear cleft. 1. **Why "Painless" is correct:** Unlike acute otitis media, there is no active infection or suppuration causing pressure on the tympanic membrane. The primary pathology is **Eustachian tube dysfunction**, leading to negative middle ear pressure and fluid transudation. The hallmark symptom is **painless hearing loss** (conductive) and a feeling of ear fullness, especially in children. 2. **Analysis of Incorrect Options:** * **Painful:** Pain (otalgia) is a feature of Acute Otitis Media (AOM) or Otitis Externa. OME is typically silent and often discovered during routine school screenings. * **Naf (Sodium Fluoride) is useful:** This is incorrect. Sodium Fluoride is used in the treatment of **Otosclerosis** (active phase/Otospongiosis) to inhibit osteoclastic activity. It has no role in managing middle ear fluid. * **Radical mastoidectomy is required:** This is an aggressive surgery for cholesteatoma or chronic suppurative otitis media (CSOM). Glue ear is managed conservatively (watchful waiting, autoinflation) or via **Myringotomy with Grommet insertion**. **High-Yield Clinical Pearls for NEET-PG:** * **Otoscopy Finding:** The tympanic membrane appears dull, opaque, and retracted. You may see **air bubbles** or an amber-colored fluid level. * **Tympanometry:** Shows a **Type B (flat) curve**, indicating fluid behind the drum. * **Treatment of Choice:** Myringotomy with Grommet insertion (usually in the antero-inferior quadrant). * **Association:** In adults, unilateral glue ear is a "red flag" and necessitates an examination of the nasopharynx to rule out **Nasopharyngeal Carcinoma**.

Q: What is the angle made by the tympanic membrane with the floor of the external auditory meatus?

55 degrees. The tympanic membrane (TM) is not positioned vertically within the ear canal; instead, it is set obliquely. In an adult, the TM forms an **angle of approximately 55 degrees** with the floor of the external auditory meatus [2]. This orientation is crucial because it increases the surface area of the membrane available for sound collection compared to a strictly vertical arrangement. * **Why 55 degrees is correct:** Anatomically, the anterior and inferior walls of the external auditory canal are longer than the posterior and superior walls. This discrepancy causes the TM to tilt, making an acute angle of 55° with the floor [2]. In neonates, this angle is even more acute, making the drum appear almost horizontal. * **Why other options are incorrect:** * **35 degrees:** This is too acute for a normal adult ear; such an angle is more characteristic of the horizontal positioning seen in newborns. * **75 degrees:** This would represent a more vertical drum than what is anatomically present. * **90 degrees:** A perpendicular orientation does not exist in human anatomy; it would significantly reduce the functional surface area of the TM. **Clinical Pearls for NEET-PG:** 1. **Cone of Light:** Due to this oblique tilt and the concavity of the drum (at the umbo), light is reflected antero-inferiorly. 2. **Anterior Recess:** The acute angle formed between the TM and the anterior canal wall creates a "recess" where debris or small foreign bodies can often become trapped [2]. 3. **Pars Tensa vs. Flaccida:** The majority of the TM is the Pars Tensa (thick), while the superior portion is the Pars Flaccida (Shrapnell’s membrane), which lacks the organized fibrous middle layer [1].

Q: What is the commonest causative organism for acute suppurative otitis media (ASOM) in a 2-year-old child?

Streptococcus pneumoniae. **Explanation:** **Streptococcus pneumoniae** is the most common causative organism for Acute Suppurative Otitis Media (ASOM) across all age groups, including children. In a 2-year-old, the Eustachian tube is shorter, wider, and more horizontal, facilitating the migration of nasopharyngeal flora into the middle ear. *S. pneumoniae* accounts for approximately 30–50% of bacterial isolates in these cases. **Analysis of Options:** * **A. Streptococcus pneumoniae (Correct):** It remains the leading pathogen globally. While the introduction of the Pneumococcal Conjugate Vaccine (PCV) has shifted the prevalence of specific serotypes, it has not displaced *S. pneumoniae* as the primary cause. * **B. Streptococcus pyogenes:** Formerly a common cause of severe ASOM with early perforation, its incidence has significantly declined in the antibiotic era. * **C. Staphylococcus aureus:** While a common cause of chronic otitis media or otitis externa, it is an infrequent primary pathogen in acute middle ear infections. * **D. Haemophilus influenzae:** This is the **second** most common cause (non-typeable *H. influenzae*). It is frequently associated with "Otitis-Conjunctivitis Syndrome" and is more likely to be found in bilateral cases or those failing initial therapy. **High-Yield Clinical Pearls for NEET-PG:** 1. **Order of Frequency:** *S. pneumoniae* > *H. influenzae* > *Moraxella catarrhalis*. 2. **Viral Etiology:** Most ASOM cases are preceded by a viral URI (RSV, Rhinovirus). 3. **Drug of Choice:** Amoxicillin remains the first-line treatment. 4. **Complication:** The most common extracranial complication of ASOM is Acute Mastoiditis.

Question 1

Which of the following statements is FALSE regarding malignant otitis externa?

Accepted Answer

Sensorineural hearing loss is a common presentation.

Answer

ESR is useful in monitoring the response to antibiotics.

Answer

It is common in diabetics.

Answer

Granulation tissue is present in the external ear canal.

Question 2

Which of the following is NOT true about Malignant otitis externa?

Accepted Answer

Completely monitored with TC99 scan till recovery

Answer

Caused by Pseudomonas Aeruginosa

Answer

Also known as Necrotising Otitis Externa

Answer

Can lead to paralysis of facial muscles

Question 3

The fistula test stimulates which structure?

Accepted Answer

Lateral semicircular canal

Answer

Posterior semicircular canal

Answer

Anterior semicircular canal

Answer

Cochlea

Question 4

A patient with a history of right ear discharge undergoes mastoidectomy. Postoperatively, the patient presents with vertigo and deafness. What is the most likely diagnosis?

Accepted Answer

Labyrinthitis

Answer

Thrombophlebitis

Answer

Temporal lobe abscess

Answer

Mastoiditis

Question 5

Which of the following statements are true about otitis media with effusion in a child?

Accepted Answer

A Type B tympanogram is observed.

Answer

Immediate myringotomy is performed.

Answer

The effusion in the middle ear is sterile.

Answer

It is the most common cause of deafness in children in daycare.

Question 6

What is the appropriate treatment for an acute stable hematoma of the pinna of the ear?

Accepted Answer

Incision, drainage, and pressure bandage

Answer

Ice packs and prophylactic antibiotics

Answer

Excision of the hematoma

Answer

Needle aspiration

Question 7

Hyperacusis is seen in all of the following conditions except:

Accepted Answer

Otosclerosis

Answer

Exposure to loud sounds

Answer

Meniere's disease

Answer

Severe head injury

Question 8

What is the characteristic of glue ear?

Accepted Answer

Painless

Answer

Painful

Answer

Naf is useful

Answer

Radical mastoidectomy is required

Question 9

What is the angle made by the tympanic membrane with the floor of the external auditory meatus?

Accepted Answer

55 degrees

Answer

35 degrees

Answer

75 degrees

Answer

90 degrees

Question 10

What is the commonest causative organism for acute suppurative otitis media (ASOM) in a 2-year-old child?

Accepted Answer

Streptococcus pneumoniae

Answer

Streptococcus pyogenes

Answer

Staphylococcus aureus

Answer

Haemophilus influenzae

Diseases of the Ear — MCQs

Diseases of the Ear — MCQs

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