Cholesteatoma — MCQs
All are intracranial complications of otitis media except which of the following?
To distinguish between cochlear and post-cochlear damage, which test is done?
Most difficult site to remove cholesteatoma from the sinus tympani is related to:
Progressive loss of hearing, tinnitus and ataxia are commonly seen in a case of -
Which of the following is not a common complication of tubercular meningitis?
Prior history of ear surgery and scanty, foul-smelling, painless discharge from the ear are characteristic features of which of the following lesions?
What is the treatment of choice for atticoantral type of chronic suppurative otitis media (CSOM)?
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?
A patient with cholesteatoma has lateral semicircular canal fistula. The most specific sign is:
Which of the following statements about tubercular otitis media is false?
Cholesteatoma Indian Medical PG Practice Questions and MCQs
Question 1: All are intracranial complications of otitis media except which of the following?
- A. Brain abscess
- B. Hydrocephalus
- C. Lateral sinus thrombophlebitis
- D. Facial nerve palsy (Correct Answer)
Explanation: ***Facial nerve palsy*** - This is an **extracranial complication** of otitis media affecting the **facial nerve within the temporal bone**, not an intracranial structure. - The facial nerve (CN VII) runs through the **fallopian canal** in the temporal bone and can be affected by inflammation from adjacent mastoid or middle ear infection. - Classified as a **temporal bone complication** rather than an intracranial complication. *Lateral sinus thrombophlebitis* - This is a true **intracranial complication** involving thrombosis of the **sigmoid and lateral venous sinuses** within the cranial cavity. - Results from direct extension of infection through the **mastoid tegmen** or via septic thrombophlebitis. - Presents with features of sepsis, headache, and papilledema. *Brain abscess* - A severe **intracranial complication** representing focal suppurative infection within the **brain parenchyma** (commonly temporal lobe or cerebellum). - Occurs through direct extension via bony erosion, retrograde thrombophlebitis, or hematogenous spread. - Requires urgent neurosurgical intervention. *Hydrocephalus* - An **intracranial complication** that can occur secondary to **otogenic meningitis** or **lateral sinus thrombosis**. - Results from impaired CSF absorption or obstruction of CSF pathways. - More common in pediatric otitis media with CNS complications.
Question 2: To distinguish between cochlear and post-cochlear damage, which test is done?
- A. Auditory brainstem response (ABR) (Correct Answer)
- B. Impedance audiometry
- C. Pure tone audiometry
- D. Electrocochleography (ECochG)
Explanation: ***Auditory brainstem response (ABR)*** - This test evaluates the integrity of the **auditory pathway from the cochlea through the brainstem**, making it excellent for differentiating between cochlear (sensory) and post-cochlear (retrocochlear/neural) lesions. - Abnormalities in wave latencies or interpeak intervals suggest **retrocochlear pathology** (e.g., acoustic neuroma), while normal ABR responses despite hearing loss point towards cochlear damage. - ABR records **five characteristic waves (I-V)** representing neural transmission from the auditory nerve through the brainstem. *Impedance audiometry* - Primarily assesses the **middle ear function**, including the eardrum and ossicles, by measuring **tympanic membrane compliance** and **acoustic reflexes**. - It does not directly evaluate the function of the **cochlea or the retrocochlear pathways**, making it unsuitable for this differentiation. *Pure tone audiometry* - Measures a person's **hearing sensitivity** at different frequencies and provides information on the **degree and type of hearing loss (conductive, sensorineural, or mixed)**. - While it identifies sensorineural hearing loss, it cannot pinpoint whether the damage is **cochlear or retrocochlear** within the sensorineural category. *Electrocochleography (ECochG)* - Records **electrical potentials generated by the cochlea and auditory nerve** in response to sound, including **cochlear microphonics, summating potentials, and compound action potentials**. - While it evaluates cochlear function and is useful in diagnosing **Meniere's disease** and **auditory neuropathy**, it does not adequately assess the **integrity of the brainstem auditory pathways** needed to differentiate retrocochlear lesions.
Question 3: Most difficult site to remove cholesteatoma from the sinus tympani is related to:
- A. Anterior facial ridge
- B. Epitympanum
- C. Hypotympanum
- D. Posterior facial ridge (Correct Answer)
Explanation: **Posterior facial ridge** - The **posterior facial ridge** forms a critical anatomical barrier, often **obscuring the sinus tympani** and making cholesteatoma removal difficult due to limited access and visibility. - Its presence necessitates careful surgical technique to avoid **facial nerve injury** while ensuring complete eradication of disease. *Anterior facial ridge* - The **anterior facial ridge** is less directly involved in defining the access to the sinus tympani, thus not posing as significant a surgical challenge for cholesteatoma removal in this specific area. - Its anatomical position typically allows for better visualization and maneuverability compared to the posterior ridge. *Epitympanum* - The **epitympanum**, while a common site for cholesteatoma, is generally more accessible surgically than the sinus tympani because of its location superior to the tympanic membrane. - Its removal often involves mastoidectomy or atticotomy, which provides direct views. *Hypotympanum* - The **hypotympanum** is located inferior to the tympanic membrane and is typically more open and accessible, allowing for easier visualization and removal of cholesteatoma. - It does not present the same deep, narrow, and obstructed surgical field as the sinus tympani, especially in relation to the facial nerve.
Question 4: Progressive loss of hearing, tinnitus and ataxia are commonly seen in a case of -
- A. Acoustic neuroma (Correct Answer)
- B. Otitis media
- C. Ependymoma
- D. Cerebral glioma
Explanation: ***Acoustic neuroma*** - This benign tumor arises from the **vestibulocochlear nerve (cranial nerve VIII)**, leading to **progressive unilateral hearing loss**, **tinnitus**, and **ataxia** as it compresses the adjacent cerebellum [1]. - The symptoms are progressive and often insidious, reflecting the slow growth of the tumor, and are highly characteristic for this condition [1]. *Otitis media* - **Otitis media** is an **inflammation/infection of the middle ear**, primarily causing ear pain, ear discharge, and conductive hearing loss. - While it causes hearing loss, it typically presents with acute symptoms and does not typically cause **tinnitus** or **ataxia** unless there are severe complications affecting the inner ear or brain. *Ependymoma* - **Ependymomas** are tumors originating from the **ependymal cells** lining the ventricles and spinal cord, often causing symptoms related to increased intracranial pressure (headache, nausea) or spinal cord compression. - They do not typically present with the specific triad of **progressive hearing loss**, **tinnitus**, and **ataxia** characteristic of acoustic neuroma. *Cerebral glioma* - **Cerebral gliomas** are brain tumors that arise from glial cells and present with a wide range of neurological symptoms depending on their location, such as **seizures**, **weakness**, or **cognitive changes**. - They are unlikely to present with the specific combination of **progressive hearing loss**, **tinnitus**, and **ataxia** unless located in the brainstem or cerebellum in a way that specifically compresses the eighth cranial nerve and cerebellar pathways, which is less common than for an acoustic neuroma.
Question 5: Which of the following is not a common complication of tubercular meningitis?
- A. Hydrocephalus
- B. Infarction
- C. Obliterative endarteritis
- D. Sinovenous thrombosis (Correct Answer)
Explanation: ***Sinovenous thrombosis*** - While possible in severe inflammatory states, **sinovenous thrombosis** is not considered a common or characteristic complication of tubercular meningitis, unlike the other mentioned complications. - The inflammatory exudates in TB meningitis primarily affect the base of the brain, leading to complications related to CSF flow and arterial compromise rather than venous sinus obstruction [1]. *Hydrocephalus* - **Hydrocephalus** is a very common complication of tubercular meningitis, resulting from obstruction of CSF flow by thick inflammatory exudates, particularly at the base of the brain [1], [2]. - The blockage can occur at various points, leading to accumulation of cerebrospinal fluid and increased intracranial pressure [2]. *Infarction* - **Infarction** (stroke) is a frequent and serious complication, caused by **vasculitis** and narrowing or occlusion of intracranial blood vessels, particularly the basal arteries [1]. - This is secondary to the extensive inflammatory exudate that surrounds and infiltrates the vessels, leading to **ischemia** and tissue death. *Obliterative endarteritis* - **Obliterative endarteritis** is the underlying pathological process leading to infarction in tubercular meningitis, involving inflammation and fibrosis of the arterial walls. - This inflammation of the small and medium-sized arteries, especially at the base of the brain, causes luminal narrowing and eventual occlusion.
Question 6: Prior history of ear surgery and scanty, foul-smelling, painless discharge from the ear are characteristic features of which of the following lesions?
- A. ASOM
- B. Cholesteatoma (Correct Answer)
- C. Central perforation
- D. Otitis externa
Explanation: ***Cholesteatoma*** - The **combination of all three features** (prior ear surgery + scanty, foul-smelling, painless discharge) is highly characteristic of cholesteatoma. - A prior history of ear surgery, particularly for **chronic otitis media**, can predispose to or be related to an **acquired cholesteatoma**. - **Scanty, foul-smelling, painless discharge** (otorrhea) is a hallmark symptom of cholesteatoma, with the **foul smell** being particularly distinctive due to breakdown of keratin debris and secondary infection. - The **painless** nature helps differentiate it from acute infections. *ASOM (Acute Suppurative Otitis Media)* - ASOM typically presents with **acute otalgia** (ear pain) and a **profuse purulent, non-foul-smelling discharge** following tympanic membrane perforation. - It is an acute infection and usually does not have a prior history of ear surgery as a direct cause of the current discharge. - The presence of **pain** and absence of foul smell distinguish it from cholesteatoma. *Central perforation* - A central perforation of the tympanic membrane often results in **intermittent, mucoid discharge** during upper respiratory tract infections, which is usually not foul-smelling. - While it can be associated with discharge, the characteristic **foul smell** and **prior surgery history** point away from simple central perforation as the primary diagnosis. - The discharge is typically more profuse during active infection. *Otitis externa* - **Otitis externa** primarily affects the ear canal, causing **pain, tenderness, and sometimes a watery or purulent discharge**, but it does not typically present with a foul-smelling discharge associated with a prior ear surgery history. - It is usually due to infection of the external auditory canal skin and not related to middle ear pathology or prior surgery in the way a cholesteatoma is. - The **painful** nature is a key distinguishing feature.
Question 7: What is the treatment of choice for atticoantral type of chronic suppurative otitis media (CSOM)?
- A. Tympanoplasty
- B. Modified radical mastoidectomy (Correct Answer)
- C. None of the options
- D. Antibiotics
Explanation: ***Modified radical mastoidectomy*** - The **atticoantral type of CSOM** is characterized by active **cholesteatoma**, which requires surgical removal to prevent further bone erosion and complications. - A **modified radical mastoidectomy** is the treatment of choice as it removes the cholesteatoma and diseased mastoid air cells while aiming to preserve residual hearing. *Antibiotics* - While topical or systemic antibiotics may be used to control acute infections or discharge in CSOM, they do not eradicate **cholesteatoma**. - **Cholesteatoma** is an epidermoid cyst that requires surgical excision, as antibiotics alone cannot resolve it. *Tympanoplasty* - **Tympanoplasty** is primarily performed to reconstruct the tympanic membrane (eardrum) and/or the ossicular chain to restore hearing. - It is typically indicated for the **tubotympanic type of CSOM** (safe type) without cholesteatoma, not for the atticoantral type which involves cholesteatoma. *None of the options* - This option is incorrect because **modified radical mastoidectomy** is a well-established and necessary treatment for the atticoantral type of CSOM involving cholesteatoma.
Question 8: 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?
- A. Stapedial abnormal bone growth
- B. Endolymphatic hydrops
- C. Cochlear hair cell degeneration (Correct Answer)
- D. Accumulation of desquamated keratin debris
Explanation: ***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.
Question 9: A patient with cholesteatoma has lateral semicircular canal fistula. The most specific sign is:
- A. Head thrust test
- B. Fistula test (Correct Answer)
- C. Hennebert's sign
- D. Dix-Hallpike test
Explanation: ***Fistula test*** - The **fistula test** (Positive pressure test or Hennebert's test) directly assesses for a communication between the middle ear and the labyrinth by applying positive or negative pressure to the external auditory canal. - A positive result, indicated by **nystagmus** or **vertigo** induced by pressure changes, is the **most specific sign** for a **labyrinthine fistula** in the context of **cholesteatoma**. - The lateral semicircular canal is the most commonly affected site in cholesteatoma-related fistulae. *Hennebert's sign* - **Hennebert's sign** refers to **nystagmus** or **vertigo** induced by pressure changes in the external auditory canal **in the absence of an actual fistula**. - It represents a **false positive fistula test** and is classically associated with **congenital syphilis**, **Meniere's disease**, or other conditions causing increased labyrinthine membrane mobility. - In this case with a **confirmed fistula**, the positive pressure test would be called a **positive fistula test**, not Hennebert's sign. *Head thrust test* - The **head thrust test** evaluates the function of the **vestibulo-ocular reflex (VOR)** and is used to detect **peripheral vestibular hypofunction**. - While cholesteatoma can affect vestibular function, this test is **not specific** for identifying a **labyrinthine fistula**. *Dix-Hallpike test* - The **Dix-Hallpike test** is used to diagnose **Benign Paroxysmal Positional Vertigo (BPPV)** by identifying nystagmus and vertigo triggered by specific head positions. - This test detects **otoconia displacement** in the semicircular canals and is **not relevant** for identifying a **labyrinthine fistula**.
Question 10: Which of the following statements about tubercular otitis media is false?
- A. Spreads through the eustachian tube
- B. Usually affects only one ear
- C. Causes painful ear discharge (Correct Answer)
- D. May cause multiple perforations
Explanation: ***Causes painful ear discharge*** - **Pain** is typically an **absent or minimal symptom** in tubercular otitis media, even with significant ear discharge. - The discharge is usually **thin, watery, and non-purulent**, reflecting the indolent nature of the infection. *Spreads through the eustachian tube* - Tubercular otitis media can spread via the **eustachian tube** from the nasopharynx, especially in cases of active pulmonary or pharyngeal tuberculosis. - This is a common route for infectious agents to reach the middle ear. *Usually affects only one ear* - Tubercular otitis media predominantly presents as a **unilateral infection**. - While bilateral involvement can occur, it is less common than unilateral presentation. *May cause multiple perforations* - Tubercular otitis media is notorious for causing **multiple, small perforations** in the tympanic membrane. - This feature, often described as a "sieve-like" drum, is a characteristic diagnostic clue for the condition.
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