Neurotology — MCQs

A 30-year-old woman with a family history of hearing loss from her mother's side developed a hearing problem during pregnancy. The hearing loss is bilateral, slowly progressive, with bilateral tinnitus that bothers her at night. Pure tone audiometry shows conductive hearing loss with an apparent bone conduction hearing loss at 2000 Hz. What is the most likely diagnosis?

Q347Easy

All of the following can cause hearing loss except?

Q348Easy

In which syndrome is sensorineural hearing loss associated with abnormality of thyroxin synthesis?

Q349Easy

The secondary tympanic membrane is present over which anatomical structure?

Q350Easy

Which graft is commonly used for tympanoplasty?

Neurotology Indian Medical PG Practice Questions and MCQs

Question 341: Which of the following signs is NOT associated with a glomus tumor?

A. Rising sun appearance
B. Aquino's sign
C. Brown's sign
D. Griesinger's sign (Correct Answer)

Explanation: **Explanation** **Griesinger's sign** is the correct answer because it is associated with **Lateral (Sigmoid) Sinus Thrombosis**, not glomus tumors. It refers to edema and tenderness over the mastoid process resulting from thrombosis and inflammation of the mastoid emissary vein. **Analysis of Glomus Tumor Signs (Incorrect Options):** Glomus tumors (Paragangliomas) are highly vascular tumors arising from the chemoreceptor cells. The following signs are characteristic: * **Rising Sun Appearance:** On otoscopy, a red/pink fleshy mass is seen behind the intact tympanic membrane, typically arising from the floor of the middle ear (Glomus jugulare) or the promontory (Glomus tympanicum). * **Brown’s Sign:** When pressure is increased in the external auditory canal using a Siegle’s speculum, the tumor pulsates more vigorously and then blanches (pales) due to the compression of its vascular supply. * **Aquino’s Sign:** Pulsations of the tumor or the patient’s synchronous tinnitus are reduced or abolished by manual compression of the ipsilateral common carotid artery. **High-Yield Clinical Pearls for NEET-PG:** * **Phelps’ Sign:** Loss of the bony septum between the jugular bulb and the carotid canal (seen on CT). * **Salt and Pepper Appearance:** Classic MRI finding (T2 weighted) representing high-flow voids (pepper) and areas of hemorrhage/slow flow (salt). * **Treatment of Choice:** Surgical excision (e.g., Transcanal or Hypotympanotomy for Glomus tympanicum). Pre-operative embolization is often used to reduce vascularity. * **Rule of 10s:** 10% are familial, 10% are multicentric, and 10% are functional (secreting catecholamines).

Question 342: Surfer's ear is described as which of the following conditions?

A. Exostosis (Correct Answer)
B. Otosclerosis
C. Otitis externa
D. Squamous cell carcinoma

Explanation: **Explanation:** **Surfer’s Ear** is the clinical eponym for **Exostosis** of the external auditory canal (EAC). 1. **Why Exostosis is correct:** Exostoses are benign, broad-based bony outgrowths of the lamellar bone in the EAC. They occur due to prolonged and repeated exposure of the canal to **cold water and wind**, which stimulates osteoblastic activity. This condition is classically seen in surfers, divers, and swimmers. They are typically **multiple, bilateral, and symmetric**, appearing as smooth, hard mucosal-covered swellings in the deep bony part of the canal. 2. **Why other options are incorrect:** * **Otosclerosis:** This is a metabolic bone disease of the otic capsule (inner ear/stapes footplate) leading to conductive hearing loss; it does not involve the external canal. * **Otitis externa:** This refers to inflammation or infection of the EAC skin (e.g., Swimmer’s ear), characterized by pain and discharge rather than bony growth. * **Squamous cell carcinoma:** This is a malignancy. While it can occur in the EAC, it presents as a friable, bleeding mass or non-healing ulcer, not as smooth bony outgrowths triggered by cold water. **High-Yield Clinical Pearls for NEET-PG:** * **Exostosis vs. Osteoma:** Unlike exostoses, an **Osteoma** is typically **solitary, unilateral, and pedunculated**, occurring at the bony-cartilaginous junction. * **Symptoms:** Most are asymptomatic but can cause conductive hearing loss or recurrent otitis externa due to the "trapping" of water and wax. * **Management:** Conservative (earplugs) for mild cases; surgical removal (canalplasty) if the canal is significantly obstructed.

Question 343: Which of the following is NOT true regarding Reinke's edema?

A. It is usually caused by vocal abuse.
B. There is a collection of edema fluid in the subepithelial space.
C. There is asymmetrical swelling of the vocal cords. (Correct Answer)
D. Vocal cord stripping is the treatment.

Explanation: **Reinke’s Edema** is a condition characterized by the accumulation of gelatinous fluid in the **subepithelial space (Reinke’s space)** of the vocal cords, located between the squamous epithelium and the vocal ligament. ### Why Option C is the Correct Answer (The False Statement) Reinke’s edema typically presents as **symmetrical, bilateral swelling** of the entire length of the membranous vocal cords. While the degree of swelling may vary slightly between sides, the hallmark of the disease is its diffuse, bilateral nature, often described as "baggy" or "polypoid" vocal cords. Therefore, stating that it is asymmetrical is incorrect. ### Analysis of Other Options * **Option A (Vocal Abuse):** This is **true**. The primary etiological factors are chronic irritation, most commonly due to **heavy smoking** and **vocal abuse** (voice strain). * **Option B (Subepithelial space):** This is **true**. Reinke’s space is a potential space with sparse lymphatic drainage, making it prone to fluid accumulation under chronic irritation. * **Option D (Vocal cord stripping):** This is **true**. While smoking cessation and voice therapy are initial steps, the definitive surgical treatment is **decortication** or "vocal cord stripping" (Micro-laryngeal surgery), where the epithelium is incised and the gelatinous fluid is aspirated/removed. ### NEET-PG High-Yield Pearls * **Clinical Presentation:** Characteristically seen in middle-aged women who smoke, presenting with a **low-pitched, "husky" voice**. * **Histopathology:** Shows edema, vascular congestion, and hyalinization of the stroma. * **Hirano’s Layers:** Reinke’s space corresponds to the **superficial layer of the lamina propria**. * **Management Tip:** Always rule out hypothyroidism, as it can present with similar vocal cord changes (Myxedema of the larynx).

Question 344: What component is surgically placed inside the ear during the implantation of a cochlear device?

A. Microphone
B. Speech processor
C. Transmitting coil
D. Receiver stimulator (Correct Answer)

Explanation: **Explanation:** A cochlear implant consists of two main parts: an **external component** and an **internally implanted component**. The **Receiver-Stimulator** is the internal component surgically placed under the skin in a bony well created in the temporal bone. It receives FM radio signals from the external transmitter, converts them into electrical pulses, and sends them to the **electrode array** (which is inserted into the *scala tympani* of the cochlea) to directly stimulate the auditory nerve. **Analysis of Incorrect Options:** * **A. Microphone:** An external component that picks up sound waves from the environment. * **B. Speech Processor:** An external component (usually worn behind the ear) that converts sound into digital signals. * **C. Transmitting Coil:** An external component held against the skin via a magnet; it transmits the processed sound to the internal receiver via induction. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** It bypasses damaged hair cells to directly stimulate the **Spiral Ganglion** (auditory nerve). * **Ideal Candidate:** Children with bilateral profound sensorineural hearing loss (SNHL) who do not benefit from hearing aids. The best results are seen in **pre-lingual** children (implanted by age 1–2) or **post-lingual** adults. * **Imaging:** HRCT of the temporal bone is mandatory to check for cochlear patency (e.g., to rule out labyrinthitis ossificans). * **Complication:** Increased risk of **Meningitis**; hence, pneumococcal vaccination is mandatory before surgery.

Question 345: The crus commune is a part of which structure?

A. Cochlea
B. Middle ear
C. Semicircular canal (Correct Answer)
D. Vestibule

Explanation: **Explanation:** The **crus commune** (common limb) is a specific anatomical feature of the vestibular system. It is formed by the fusion of the non-ampullated ends of the **superior (anterior) and posterior semicircular canals**. These two canals join together to form a single duct before opening into the vestibule. * **Why C is correct:** The semicircular canals (SCC) consist of three loops. While each canal has an ampullated end, the non-ampullated ends of the superior and posterior canals merge into the **crus commune**. The lateral (horizontal) SCC is the only one that does not participate in this fusion, opening independently into the vestibule. * **Why A is incorrect:** The cochlea is the snail-shaped organ for hearing. Its primary anatomical divisions include the scala vestibuli, scala media, and scala tympani. * **Why B is incorrect:** The middle ear contains the ossicles (malleus, incus, stapes) and the Eustachian tube. The crus commune is a part of the bony labyrinth located in the inner ear. * **Why D is incorrect:** While the crus commune *opens into* the vestibule, it is structurally considered a part of the semicircular canal system. **High-Yield Clinical Pearls for NEET-PG:** 1. **Total Openings:** There are **5 openings** of the semicircular canals into the vestibule (not 6), because of the crus commune. 2. **Superior Canal Dehiscence:** A clinical condition where the bony covering of the superior SCC is missing, leading to the **Tullio phenomenon** (sound-induced vertigo). 3. **Caloric Test:** Primarily tests the **lateral (horizontal) semicircular canal**, as it is the most accessible for thermal stimulation.

Question 346: A 30-year-old woman with a family history of hearing loss from her mother's side developed a hearing problem during pregnancy. The hearing loss is bilateral, slowly progressive, with bilateral tinnitus that bothers her at night. Pure tone audiometry shows conductive hearing loss with an apparent bone conduction hearing loss at 2000 Hz. What is the most likely diagnosis?

A. Otosclerosis (Correct Answer)
B. Acoustic neuroma
C. Otitis media with effusion
D. Sigmoid sinus thrombosis

Explanation: ### Explanation **Otosclerosis** is the most likely diagnosis based on the classic clinical triad presented: **bilateral progressive conductive hearing loss (CHL)**, a positive **family history** (autosomal dominant with incomplete penetrance), and **aggravation during pregnancy** (due to hormonal changes accelerating the remodeling of the otic capsule). The "apparent bone conduction hearing loss at 2000 Hz" is the pathognomonic **Carhart’s Notch**. This is not a true sensorineural loss but a mechanical artifact caused by the stapes fixation, which disrupts the natural resonance of the ossicular chain. #### Why the other options are incorrect: * **Acoustic Neuroma:** Presents with unilateral sensorineural hearing loss (SNHL) and balance issues, not bilateral CHL. It is not influenced by pregnancy. * **Otitis Media with Effusion (OME):** While it causes CHL, it is usually preceded by upper respiratory infections and does not typically present with a family history or a specific 2000 Hz notch. * **Sigmoid Sinus Thrombosis:** A serious complication of chronic suppurative otitis media (CSOM). It presents with "picket-fence" fever, headache, and signs of raised intracranial pressure, not isolated progressive hearing loss. #### High-Yield Clinical Pearls for NEET-PG: * **Schwartz Sign:** A flamingo-pink blush seen on the promontory through the TM, indicating active otosclerosis (Otospongiosis). * **Gelle’s Test:** Negative in otosclerosis (indicates fixed ossicles). * **Bezold’s Triad:** 1. Negative Rinne test, 2. Raised bone conduction threshold (Carhart’s notch), 3. Low-frequency hearing loss. * **Treatment of Choice:** Stapedotomy (using a Teflon piston). Sodium fluoride can be used to medically stabilize active disease.

Question 347: All of the following can cause hearing loss except?

A. Measles
B. Chickenpox (Correct Answer)
C. Mumps
D. Rubella

Explanation: **Explanation:** The correct answer is **Chickenpox (Varicella Zoster Virus)**. While the primary infection (Chickenpox) typically presents with a generalized pruritic rash and fever, it is rarely associated with sensorineural hearing loss (SNHL). In contrast, the reactivation of the virus (Herpes Zoster Oticus/Ramsay Hunt Syndrome) is a well-known cause of hearing loss and facial palsy, but the initial Chickenpox infection itself is not a classic cause of deafness. **Analysis of Incorrect Options:** * **Mumps:** This is the **most common cause of acquired unilateral SNHL** in children. The hearing loss is typically sudden, profound, and permanent. It occurs due to endolymphatic labyrinthitis. * **Measles (Rubeola):** This can cause bilateral, severe to profound SNHL. The virus reaches the inner ear via the bloodstream (hematogenous spread), leading to permanent damage to the Organ of Corti. * **Rubella (German Measles):** This is a classic cause of **Congenital SNHL**. If a mother is infected during the first trimester, the virus crosses the placenta, leading to the "Classic Triad": Cataracts, Cardiac defects (PDA), and Cochlear deafness (SNHL). **High-Yield Clinical Pearls for NEET-PG:** 1. **Mumps:** Most common cause of unilateral SNHL in children. 2. **Maternal Rubella:** Most common viral cause of congenital SNHL (Scheibe Dysplasia). 3. **Cytomegalovirus (CMV):** The overall most common non-genetic cause of congenital SNHL. 4. **Ramsay Hunt Syndrome:** Caused by reactivation of Varicella Zoster in the geniculate ganglion; presents with vesicles on the pinna, facial palsy, and SNHL.

Question 348: In which syndrome is sensorineural hearing loss associated with abnormality of thyroxin synthesis?

A. Alport syndrome
B. Pendred syndrome (Correct Answer)
C. Klippel-Feil syndrome
D. Usher syndrome

Explanation: **Explanation:** **Pendred Syndrome** is an autosomal recessive disorder caused by a mutation in the **SLC26A4 gene**, which encodes the protein **pendrin**. Pendrin is an ion exchanger found in the inner ear and the thyroid gland. 1. **In the Thyroid:** It is responsible for iodide transport. A defect leads to impaired organification of iodine, resulting in a multinodular goiter (euthyroid or mildly hypothyroid). 2. **In the Inner Ear:** It leads to **bilateral sensorineural hearing loss (SNHL)**, typically associated with structural malformations like an **enlarged vestibular aqueduct (EVA)** or Mondini dysplasia. **Analysis of Incorrect Options:** * **Alport Syndrome:** Characterized by SNHL associated with **progressive renal failure** and ocular abnormalities (lenticonus) due to a defect in Type IV collagen. * **Klippel-Feil Syndrome:** Defined by the clinical triad of a short neck, low posterior hairline, and restricted neck motion due to **fused cervical vertebrae**. It may be associated with hearing loss (Wildervanck syndrome) but not thyroid issues. * **Usher Syndrome:** The most common cause of combined deafness and blindness. It involves SNHL associated with **Retinitis Pigmentosa**. **High-Yield Clinical Pearls for NEET-PG:** * **Perchlorate Discharge Test:** Historically used to diagnose Pendred syndrome; it shows an abnormal washout of iodine from the thyroid. * **Radiology:** The most common radiological finding in Pendred syndrome is a **dilated/enlarged vestibular aqueduct**. * **Mnemonic:** Remember **P**endred = **P**erchlorate test, **P**endrin protein, and **P**artial thyroid defect.

Question 349: The secondary tympanic membrane is present over which anatomical structure?

A. Round window (Correct Answer)
B. Oval window
C. Lateral wall of middle ear
D. Scala media

Explanation: ### Explanation **Correct Answer: A. Round window** The **secondary tympanic membrane** is a thin, three-layered membrane that seals the **round window (fenestra rotunda)**, separating the middle ear cavity from the scala tympani of the cochlea. **Underlying Concept:** In the physiology of hearing, the stapes footplate pushes into the oval window, creating a pressure wave in the perilymph. Because fluids are incompressible and the cochlea is encased in bone, there must be a "pressure relief valve" to allow this fluid movement. The secondary tympanic membrane bulges outward into the middle ear to compensate for the inward movement of the stapes, facilitating the traveling wave along the basilar membrane. **Analysis of Incorrect Options:** * **B. Oval window (Fenestra vestibuli):** This is closed by the **footplate of the stapes** and the annular ligament, not a membrane. It is the entry point for sound energy. * **C. Lateral wall of middle ear:** This is primarily formed by the **tympanic membrane** (primary) and the bony lateral wall (scutum). * **D. Scala media:** This is the middle compartment of the cochlea containing endolymph. It is bounded by Reissner’s membrane and the basilar membrane, not the secondary tympanic membrane. **High-Yield Clinical Pearls for NEET-PG:** * **Layers:** Like the primary tympanic membrane, the secondary membrane has three layers: outer (mucous), middle (fibrous), and inner (endothelial). * **Round Window Reflex:** During surgery, if the stapes is moved, the round window membrane can be seen to move; its absence may indicate otosclerosis or middle ear pathology. * **Round Window Niche:** The membrane is located at the bottom of a funnel-shaped depression called the round window niche, which is an important landmark in cochlear implant surgery. * **Drug Delivery:** The round window membrane is the primary route for **intratympanic gentamicin or steroid injections** to reach the inner ear via semi-permeable diffusion.

Question 350: Which graft is commonly used for tympanoplasty?

A. Antral fascia
B. Temporalis fascia (Correct Answer)
C. Pre-auricular fascia
D. Post-auricular fascia

Explanation: **Explanation:** **Temporalis fascia** is the most commonly used graft material for tympanoplasty (Type I) due to its excellent anatomical and physiological properties. **Why Temporalis Fascia is the Gold Standard:** 1. **Low Metabolic Rate:** It has a very low oxygen requirement, allowing it to survive as a "free graft" until revascularization occurs. 2. **Acoustic Properties:** Its thickness and elasticity closely mimic the natural tympanic membrane, ensuring excellent sound conduction. 3. **Accessibility:** It is easily harvested through the same surgical incision (post-aural or endaural) used for the ear surgery. 4. **Success Rate:** It boasts a high "take" rate (80–90%) and is resistant to infection. **Analysis of Incorrect Options:** * **A. Antral fascia:** This is not a standard anatomical term for a graft site in otology. * **C & D. Pre-auricular and Post-auricular fascia:** While the skin in these areas is used for various flaps, the underlying fascia is not thick or resilient enough to serve as a primary graft for the tympanic membrane compared to the robust temporalis fascia. **High-Yield Clinical Pearls for NEET-PG:** * **Other Graft Materials:** Tragal perichondrium (used in revision cases or total perforations), cartilage (used for atelectatic ears to prevent retraction), and vein grafts. * **Wullstein Classification:** Remember that Type I tympanoplasty is also known as **Myringoplasty** (repair of the drum only). * **Placement:** The graft is most commonly placed using the **Underlay technique** (medial to the handle of the malleus and the fibrous layer of the remnant drum) to prevent lateralization.

Practice by Chapter

Vestibular System Anatomy and Physiology

Practice Questions

Vestibular Testing

Practice Questions

Benign Paroxysmal Positional Vertigo

Practice Questions

Ménière's Disease

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Vestibular Neuritis

Practice Questions

Labyrinthitis

Practice Questions

Acoustic Neuroma

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Other Cerebellopontine Angle Tumors

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Facial Nerve Disorders

Practice Questions

Skull Base Surgery

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Cochlear Implantation

Practice Questions

Vestibular Schwannoma Management

Practice Questions

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