Otology — MCQs

Otology Indian Medical PG Practice Questions and MCQs

Question 11: Painless discharge from the ear and multiple tympanic membrane perforations are characteristic of?

A. Tuberculous otitis media (Correct Answer)
B. Fungal otitis media
C. Serous otitis media
D. Viral otitis media

Explanation: **Explanation:** The correct answer is **Tuberculous Otitis Media (TOM)**. This is a chronic granulomatous infection of the middle ear caused by *Mycobacterium tuberculosis*. **Why Tuberculous Otitis Media is correct:** The classic clinical triad of TOM includes: 1. **Painless ear discharge:** Unlike pyogenic otitis media, the onset is insidious and painless. 2. **Multiple tympanic membrane perforations:** These occur due to the coalescence of multiple small tubercles on the drum. 3. **Profound hearing loss:** Often out of proportion to the clinical findings due to early inner ear involvement. Other features include pale granulations in the middle ear and early facial nerve paralysis. **Why the other options are incorrect:** * **Fungal Otitis Media (Otomycosis):** Characterized by intense itching, pain, and a "wet newspaper" or "velvety" appearance of the canal (due to *Aspergillus* or *Candida*). It does not typically cause multiple perforations. * **Serous Otitis Media (Otitis Media with Effusion):** Presents with an intact, retracted tympanic membrane and conductive hearing loss. There is no discharge or perforation. * **Viral Otitis Media:** Usually presents as Bullous Myringitis (painful vesicles on the drum) or as part of an upper respiratory infection. It does not cause chronic painless discharge or multiple perforations. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Culture of the discharge on Lowenstein-Jensen (LJ) medium or demonstration of Acid-Fast Bacilli (AFB) on smear. * **Pathognomonic sign:** Multiple perforations (though these may later coalesce into a single large central perforation). * **Treatment:** Standard Anti-Tubercular Therapy (ATT) for 6 months. Surgery is reserved for complications like mastoiditis or facial palsy.

Question 12: What is indicated by Tobey Ayer's Test?

A. Acute mastoiditis with lateral sinus thrombosis (Correct Answer)
B. Maxillary cancer with spread to nasal cavity
C. Rhinosporidiosis
D. Jugular vein thrombosis

Explanation: **Tobey-Ayer Test** (also known as the Queckenstedt-Stookey Test) is a clinical maneuver used to diagnose **Lateral (Sigmoid) Sinus Thrombosis**, a serious complication of acute or chronic mastoiditis. ### **Explanation of the Correct Answer** The test is based on the dynamics of cerebrospinal fluid (CSF) pressure. In a healthy individual, manual compression of one or both internal jugular veins (IJV) causes a rapid rise in CSF pressure (measured via lumbar puncture) because venous outflow from the brain is obstructed. * **In Lateral Sinus Thrombosis:** If the affected side's IJV is compressed, there is **no rise** (or a negligible rise) in CSF pressure because the sinus is already occluded by a thrombus. * Conversely, compressing the healthy side causes a disproportionately **sharp and rapid rise** in pressure, as the entire venous drainage is forced through a single patent channel. ### **Analysis of Incorrect Options** * **B & C (Maxillary Cancer/Rhinosporidiosis):** These are pathologies of the paranasal sinuses and nasal mucosa. They do not involve the intracranial venous sinuses or affect CSF pressure dynamics. * **D (Jugular Vein Thrombosis):** While the test involves the jugular vein, it is specifically designed to identify the extension of the thrombus into the **lateral/sigmoid sinus** in the context of middle ear infections. Isolated jugular thrombosis is usually diagnosed via Doppler ultrasound or CT. ### **High-Yield Clinical Pearls for NEET-PG** * **Griesinger’s Sign:** Edema over the mastoid process due to thrombosis of the mastoid emissary vein (another classic sign of Lateral Sinus Thrombosis). * **Crowe-Beck Test:** Engorgement of retinal veins and conjunctiva upon compression of the healthy IJV (the ophthalmological equivalent of the Tobey-Ayer test). * **Delta Sign:** Seen on contrast-enhanced CT, representing a thrombus in the superior sagittal or sigmoid sinus. * **Treatment:** The standard approach is Mastoidectomy with decompression of the sinus and intravenous antibiotics. Anticoagulants are controversial but used if the thrombus propagates.

Question 13: In otitis media, how is Weber's test typically lateralized?

A. Not lateralized
B. Lateralized to the poorer ear (Correct Answer)
C. Lateralized to the better ear
D. Inconclusive

Explanation: ### Explanation **Concept:** Otitis media (whether acute or serous) causes **Conductive Hearing Loss (CHL)** due to fluid or pressure in the middle ear interfering with the ossicular conduction of sound. In **Weber’s test**, a vibrating tuning fork (512 Hz) is placed on the midline of the skull. In CHL, the sound is **lateralized to the poorer ear** (the ear with the conductive deficit). This occurs because the "masking effect" of ambient room noise is reduced in the affected ear, and there is an increase in bone conduction sensitivity (the Stenger phenomenon). Essentially, the cochlea in the diseased ear is normal but is better able to perceive bone-conducted sound because it isn't competing with external environmental noise. **Analysis of Options:** * **Option B (Correct):** In CHL (as seen in otitis media), Weber lateralizes to the diseased/poorer ear. * **Option C (Incorrect):** Lateralization to the **better ear** occurs in **Sensorineural Hearing Loss (SNHL)**. If a patient had permanent nerve damage in one ear, they would hear the vibration better in the healthy ear. * **Option A & D (Incorrect):** Weber is "not lateralized" (central) in individuals with normal hearing or symmetrical hearing loss. It is a highly sensitive test for identifying asymmetrical hearing loss. **NEET-PG High-Yield Pearls:** * **Rinne Test in Otitis Media:** Will be **Negative** (Bone Conduction > Air Conduction), which is the hallmark of CHL. * **ABC (Absolute Bone Conduction) Test:** In otitis media, ABC is **normal**, as the inner ear (cochlea) is unaffected. * **Gelle’s Test:** Used to check ossicular chain patency; it is **negative** in conditions like Otosclerosis or Otitis Media where the middle ear mechanism is stiffened. * **The "Rule of Thumb":** Weber to the bad ear = Conductive; Weber to the good ear = Sensorineural.

Question 14: Fluctuating recurring variable sensorineural deafness is seen in:

A. Serous otitis media
B. Haemotympanum
C. Perilabyrinthine fistula (Correct Answer)
D. Labyrinthine concussion

Explanation: ### Explanation **Correct Answer: C. Perilabyrinthine fistula** A **Perilabyrinthine (or Perilymph) fistula** is an abnormal communication between the fluid-filled inner ear (perilymphatic space) and the air-filled middle ear, most commonly occurring at the round or oval window. * **Mechanism:** The leakage of perilymph leads to sudden or episodic changes in inner ear pressure. This results in **fluctuating sensorineural hearing loss (SNHL)** and episodic vertigo. The hearing loss is "variable" because it can worsen with physical exertion, coughing, or sneezing (Valsalva maneuver), which increases intracranial or middle ear pressure. * **Clinical Sign:** A positive **Hennebert’s sign** (vertigo/nystagmus induced by pressure changes in the external ear canal) is a classic finding. **Why other options are incorrect:** * **A & B (Serous otitis media & Haemotympanum):** These conditions involve fluid or blood in the middle ear, which interferes with the ossicular chain's vibration. Therefore, they cause **Conductive Hearing Loss (CHL)**, not sensorineural deafness. * **D (Labyrinthine concussion):** This usually results from head trauma. While it causes SNHL, the hearing loss is typically **sudden and stable** (non-fluctuating) or may gradually improve; it does not present with recurring, variable fluctuations. **High-Yield Clinical Pearls for NEET-PG:** * **Meniere’s Disease** also presents with fluctuating SNHL, but it is characterized by the triad of vertigo, tinnitus, and aural fullness, often with low-frequency SNHL initially. * **Management of Fistula:** Initial management is strict bed rest with head elevation. If symptoms persist, surgical exploration and patching of the windows are required. * **Tullio Phenomenon:** Vertigo induced by loud sounds; often seen in perilymph fistula and Superior Semicircular Canal Dehiscence (SSCD).

Question 15: All the following are features of Gradenigo's syndrome except?

A. Flushing of skin over parotid (Correct Answer)
B. Retro orbital pain
C. VI nerve palsy
D. Persistent ear discharge

Explanation: **Gradenigo’s Syndrome** is a classic clinical triad resulting from **Petrositis** (infection spreading to the petrous apex of the temporal bone), typically as a complication of chronic suppurative otitis media (CSOM). [1] ### Explanation of Options: * **Correct Answer: Flushing of skin over parotid (Option A)** This is the correct answer because it is **not** a feature of Gradenigo’s syndrome. Flushing and sweating over the parotid region during mastication is characteristic of **Frey’s Syndrome** (auriculotemporal nerve injury), usually following parotid surgery. It has no anatomical or pathological link to petrositis. * **Retro-orbital pain (Option B):** This is caused by irritation of the **Trigeminal nerve (Vth cranial nerve)**, specifically the Gasserian ganglion, which lies in Meckel’s cave near the petrous apex. [1] * **VI nerve palsy (Option C):** The **Abducens nerve** passes through **Dorello’s canal** beneath the petrosphenoid ligament. Inflammation at the petrous apex compresses the nerve, leading to lateral rectus palsy and diplopia. [2] * **Persistent ear discharge (Option D):** This represents the underlying **Otorrhoea** associated with the primary middle ear infection/mastoiditis that leads to petrositis. [1] ### Clinical Pearls for NEET-PG: 1. **The Triad:** 1. Abducens (VI) nerve palsy, 2. Retro-orbital pain (V nerve), 3. Otorrhoea. [2] 2. **Anatomy:** Dorello’s canal is the most vulnerable site for the VI nerve in this syndrome. 3. **Investigation:** **MRI** is the gold standard to visualize marrow changes in the petrous apex, though CT shows bone destruction. [1] 4. **Treatment:** Intensive IV antibiotics and surgical drainage (e.g., cortical or radical mastoidectomy with petrous apicectomy). [1]

Question 16: All are true about cochlear implant except?

A. Minimum age is 1 year
B. PTA of 70 dB or more
C. Switch on is done after 3 weeks
D. MRI has no role in pre-operative assessment (Correct Answer)

Explanation: **Explanation:** The correct answer is **D (MRI has no role in pre-operative assessment)** because MRI is, in fact, a **mandatory** part of the pre-operative evaluation for a cochlear implant. While a High-Resolution CT (HRCT) of the temporal bone assesses the bony anatomy (e.g., cochlear patency, facial nerve course), an **MRI (3D-CISS/FIESTA sequence)** is essential to visualize the soft tissues. It confirms the presence of the vestibulocochlear nerve (CN VIII) and rules out cochlear nerve aplasia, labyrinthitis ossificans, or internal auditory canal stenosis, which would contraindicate the procedure. **Analysis of other options:** * **A. Minimum age is 1 year:** This is generally true for congenital deafness. Early implantation (12–24 months) takes advantage of maximum neuroplasticity during the critical period of language development. * **B. PTA of 70 dB or more:** Cochlear implants are indicated for individuals with **severe to profound sensorineural hearing loss (SNHL)** who derive minimal benefit from conventional hearing aids. A Pure Tone Average (PTA) of >70 dB (severe) or >90 dB (profound) is a standard criterion. * **C. Switch on is done after 3 weeks:** The external processor is typically "switched on" and mapped 3 to 4 weeks post-surgery. This delay allows for adequate wound healing and the subsidence of post-operative edema. **Clinical Pearls for NEET-PG:** * **Ideal Candidate:** A post-lingual deaf adult or a pre-lingual deaf child (best results if implanted before age 5). * **The Electrode:** It is placed in the **Scala Tympani** of the cochlea. * **Contraindications:** Absence of the cochlear nerve, complete cochlear agenesis (Michel deformity), and active middle ear infections. * **Meningitis Risk:** Patients must be vaccinated against *Streptococcus pneumoniae* prior to surgery due to the increased risk of meningitis.

Question 17: A 7-year-old child presenting with acute otitis media does not respond to ampicillin. Examination reveals a full and bulging tympanic membrane. What is the treatment of choice?

A. Systemic steroid
B. Ciprofloxacin
C. Myringotomy (Correct Answer)
D. Cortical mastoidectomy

Explanation: **Explanation:** The clinical presentation describes a case of **Acute Otitis Media (AOM)** that has failed medical management (ampicillin) and is showing signs of significant middle ear pressure (full and bulging tympanic membrane). **Why Myringotomy is the Correct Answer:** Myringotomy is the surgical incision of the tympanic membrane. In AOM, it is indicated when there is a **failure of medical therapy**, severe earache with a bulging drum, or an impending complication (like facial nerve palsy or mastoiditis). By creating an opening, it provides immediate pain relief by decompressing the middle ear and allows for the drainage of pus, which can be sent for culture and sensitivity to guide further antibiotic therapy. **Analysis of Incorrect Options:** * **Systemic Steroids (A):** These have no role in the primary management of AOM. They are occasionally used in Otitis Media with Effusion (OME) or certain complications, but not for an acute bulging drum. * **Ciprofloxacin (B):** While changing the antibiotic is a consideration, the immediate physical requirement for a "full and bulging" drum that failed initial treatment is drainage. Furthermore, fluoroquinolones are generally avoided as first-line systemic therapy in young children unless specifically indicated by cultures. * **Cortical Mastoidectomy (D):** This is a more invasive procedure reserved for cases of **Coalescent Mastoiditis**. While AOM can lead to mastoiditis, the first step for a bulging drum is simple drainage via myringotomy. **Clinical Pearls for NEET-PG:** * **Most common site for Myringotomy:** Postero-inferior quadrant (to avoid the ossicles and the chorda tympani nerve). * **Indications for Myringotomy in AOM:** Bulging drum with severe pain, persistent fever despite antibiotics, or presence of intracranial/extracranial complications. * **Most common organism in AOM:** *Streptococcus pneumoniae*, followed by *Haemophilus influenzae*.

Question 18: What is the commonest site of otosclerosis?

A. Round window
B. Oval window (Correct Answer)
C. Utricle
D. Ossicles

Explanation: **Explanation:** Otosclerosis is a primary metabolic bone disease of the otic capsule characterized by abnormal bone resorption and deposition. **Why the Oval Window is Correct:** The most common site of involvement in otosclerosis is the **fissula ante fenestram**, which is a small area located just **anterior to the oval window**. When the otosclerotic focus involves this area, it leads to the fixation of the stapes footplate (stapedial otosclerosis), resulting in progressive conductive hearing loss. This is the hallmark clinical presentation of the disease. **Analysis of Incorrect Options:** * **Round Window:** While the round window is the second most common site for otosclerotic foci, it is significantly less frequent than the oval window. Involvement here can lead to "obliterative otosclerosis." * **Utricle:** The utricle is a membranous labyrinth structure involved in balance. Otosclerosis is a disease of the bony otic capsule, not the membranous labyrinth. * **Ossicles:** While the stapes footplate is involved, the term "ossicles" is too broad. The disease process originates in the bony labyrinth (otic capsule) and secondarily affects the stapes; it does not typically primary involve the malleus or incus. **High-Yield Clinical Pearls for NEET-PG:** * **Schwartze Sign:** A flamingo-pink flush seen through the tympanic membrane due to increased vascularity in active otosclerosis (Otospongiosis). * **Carhart’s Notch:** A characteristic dip in the bone conduction audiogram at **2000 Hz**. * **Gelle’s Test:** Negative (indicates stapes fixation). * **Treatment of Choice:** Stapedotomy or Stapedectomy. * **Medical Management:** Sodium fluoride (to mature active foci).

Question 19: Which of the following statements about the pinna is true, except?

A. In Treacher-Collins syndrome, a malformed pinna may be present.
B. It is made up of elastic cartilage.
C. It develops from the first pharyngeal cleft only. (Correct Answer)
D. It helps in the localization of sound.

Explanation: ### Explanation **1. Why Option C is the Correct Answer (The False Statement)** The pinna does **not** develop from the first pharyngeal cleft alone. It develops from **six auricular hillocks (Hillocks of His)**, which are mesenchymal proliferations derived from both the **first pharyngeal arch (Mandibular arch)** and the **second pharyngeal arch (Hyoid arch)**. * Hillocks 1, 2, and 3 arise from the 1st arch. * Hillocks 4, 5, and 6 arise from the 2nd arch. The first pharyngeal cleft actually gives rise to the **External Auditory Canal (EAC)**. **2. Analysis of Other Options** * **Option A:** Treacher-Collins syndrome (Mandibulofacial dysostosis) is a first and second branchial arch syndrome. It frequently presents with microtia (malformed pinna), atresia of the EAC, and ossicular anomalies. * **Option B:** The framework of the pinna consists of a single piece of **yellow elastic cartilage**. Note that the lobule is the only part of the pinna that lacks cartilage (it contains fat and fibrous tissue). * **Option C:** The pinna acts as a funnel to collect sound waves and its complex ridges (concha, tragus) are essential for **vertical sound localization** and directing sound into the EAC. **3. High-Yield Clinical Pearls for NEET-PG** * **Tragus Development:** Derived from the **1st arch** (1st hillock). * **Pre-auricular Sinus:** Caused by incomplete fusion of the auricular hillocks. * **Nerve Supply:** The pinna has a complex nerve supply: Greater auricular (C2, C3), Lesser occipital (C2), Auriculotemporal (V3), and the Facial (VII) and Vagus (X) nerves (Arnold’s nerve). * **Bat Ear:** A deformity where the concha-scaphal angle is >90° (normal is ~30°).

Question 20: What is the commonest cause of acute otitis media in children?

A. Haemophilus influenzae
B. Streptococcus pneumoniae (Correct Answer)
C. Staphylococcus aureus
D. Pseudomonas

Explanation: **Explanation:** **Acute Otitis Media (AOM)** is a common pediatric infection characterized by inflammation of the middle ear. The correct answer is **Streptococcus pneumoniae**, which remains the most frequent bacterial pathogen isolated from middle ear fluid in children worldwide. 1. **Streptococcus pneumoniae (Correct):** It accounts for approximately 30–50% of bacterial cases. While the introduction of the pneumococcal conjugate vaccine (PCV) has shifted the prevalence of specific serotypes, *S. pneumoniae* remains the leading cause overall. 2. **Haemophilus influenzae (Incorrect):** This is the second most common cause (non-typeable strains). Since the PCV vaccine reduced *S. pneumoniae* rates, the relative proportion of *H. influenzae* has increased, and it is frequently associated with concurrent conjunctivitis (Otitis-Conjunctivitis Syndrome). 3. **Staphylococcus aureus (Incorrect):** While it can cause middle ear infections, it is a rare cause of AOM. It is more commonly associated with chronic suppurative otitis media (CSOM) or furunculosis of the external ear. 4. **Pseudomonas (Incorrect):** *Pseudomonas aeruginosa* is the hallmark pathogen of **Chronic Suppurative Otitis Media (CSOM)** and **Otitis Externa** (including Malignant Otitis Externa), but it is not a primary cause of AOM. **High-Yield Clinical Pearls for NEET-PG:** * **Most common route of infection:** Eustachian tube (retrograde spread from the nasopharynx). * **Most common viral cause:** Respiratory Syncytial Virus (RSV) and Rhinovirus. * **Drug of Choice:** Amoxicillin (High dose) is the first-line treatment. * **Cartwheel Appearance:** Seen during the Stage of Suppuration (bulging TM with radiating vessels). * **Lighthouse Sign:** A pulsating light reflex seen on the tympanic membrane during the Stage of Resolution/Perforation.

Practice by Chapter

Tympanic Membrane Perforation

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Cholesteatoma

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Tympanoplasty Techniques

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Ossicular Chain Reconstruction

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Mastoidectomy

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Stapedectomy

Practice Questions

Implantable Hearing Devices

Practice Questions

Congenital Aural Atresia

Practice Questions

Otologic Trauma

Practice Questions

Glomus Tumors

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Facial Nerve Decompression

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Rehabilitative Audiology

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Otology — MCQs

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