Otology — MCQs

A 3-year-old girl ruptured her eardrum when she inserted a pencil into her external ear canal. She was urgently admitted to the emergency department. Physical examination revealed pain in her ear and a few drops of blood in the external auditory meatus. There was concern that there might possibly have been an injury to the nerve that principally innervates the external surface of the tympanic membrane. Which of the following tests is most likely to be performed during physical examination to check for injury to this nerve?

Q36Easy

Hypoacusis is caused by paralysis of which of the following muscles?

Q37Medium

Greisinger's sign is suggestive of:

Q38Medium

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 and slowly progressive. Pure tone audiometry shows an apparent bone conduction hearing loss at 2000 Hz. What is the most likely diagnosis?

Q39Easy

Otomycosis is caused by which of the following organisms?

Q40Easy

What is tympanoplasty?

Otology Indian Medical PG Practice Questions and MCQs

Question 31: All are true about transverse fracture of the temporal bone except?

A. Facial nerve commonly involved
B. Sensorineural deafness
C. Conductive deafness (Correct Answer)
D. These fractures are less common

Explanation: Temporal bone fractures are traditionally classified as **Longitudinal** (80%) or **Transverse** (20%) based on their relationship to the long axis of the petrous bone. ### **Why "Conductive Deafness" is the Correct Answer (The Exception)** Transverse fractures typically run perpendicular to the petrous ridge, crossing the bony labyrinth (cochlea and vestibule) and the internal auditory canal. This results in **Sensorineural Hearing Loss (SNHL)** and severe vertigo due to direct damage to the inner ear structures. **Conductive deafness** is a hallmark of *longitudinal* fractures, where the fracture line involves the middle ear, causing ossicular disruption or tympanic membrane rupture. ### **Analysis of Other Options** * **A. Facial nerve commonly involved:** True. Facial nerve paralysis occurs in approximately **50%** of transverse fractures (compared to only 15-20% in longitudinal) because the fracture line often crosses the fallopian canal or internal auditory meatus. * **B. Sensorineural deafness:** True. As the fracture line transects the cochlea or the 8th cranial nerve, permanent SNHL is the expected outcome. * **D. These fractures are less common:** True. Transverse fractures account for only about **20%** of all temporal bone fractures and usually result from severe frontal or occipital blows. ### **High-Yield Clinical Pearls for NEET-PG** | Feature | Longitudinal Fracture (80%) | Transverse Fracture (20%) | | :--- | :--- | :--- | | **Force Direction** | Lateral (Temporal/Parietal) | Frontal or Occipital | | **Hearing Loss** | **Conductive** (Common) | **Sensorineural** (Common) | | **Facial Nerve** | Less common (15-20%) | **More common (50%)** | | **Otics Capsule** | Spared | **Involved** | | **Bleeding** | Bleeding from ear (common) | Hemotympanum (intact TM) | | **CSF Otorrhea** | More common | Less common |

Question 32: Bezold abscess is seen in:

A. Sternocleidomastoid Muscle (Correct Answer)
B. Sternohyoid muscle
C. Saorius muscle
D. Semimembranosus muscle

Explanation: **Explanation:** **Bezold abscess** is a rare complication of acute coalescent mastoiditis. It occurs when the infection erodes through the thin inner cortical bone of the **mastoid tip** (medial to the attachment of the sternocleidomastoid muscle). 1. **Why Option A is Correct:** The pus tracks downwards from the mastoid tip into the **sheath of the Sternocleidomastoid (SCM) muscle**. Because the mastoid tip bone is thinner on its medial aspect, the infection escapes the bone and presents as a deep neck swelling in the upper part of the neck, obscured by the SCM muscle. 2. **Why Other Options are Incorrect:** * **Sternohyoid muscle (B):** This is an infrahyoid "strap" muscle of the neck. It is located too anteriorly and medially to be involved in mastoid tip infections. * **Sartorius muscle (C):** This is the longest muscle in the human body, located in the **thigh**. It has no anatomical relation to the temporal bone. * **Semimembranosus muscle (D):** This is one of the hamstring muscles located in the **posterior compartment of the thigh**. **Clinical Pearls for NEET-PG:** * **Luc’s Abscess:** Pus tracks through the external auditory canal wall (subperiosteal abscess). * **Citelli’s Abscess:** Pus tracks into the posterior belly of the digastric muscle, presenting in the digastric triangle. * **Clinical Presentation:** Patients with Bezold abscess often present with neck pain, fever, and a "torticollis" (wry neck) due to irritation of the SCM. * **Diagnosis:** Contrast-enhanced CT (CECT) is the gold standard to visualize the mastoiditis and the extent of the neck abscess.

Question 33: The Phlep sign is seen in which of the following conditions?

A. Otosclerosis
B. Meniere's disease
C. Lateral sinus thrombosis
D. Glomus tumor (Correct Answer)

Explanation: **Explanation:** The **Phelps sign** (often referred to as the Phlep sign in some Indian medical texts) is a characteristic radiological finding seen in **Glomus Jugulare** tumors. It refers to the **erosion of the bony septum** (the carotico-jugular crest) that separates the jugular bulb from the carotid canal. This sign is best visualized on a high-resolution CT scan of the temporal bone and helps differentiate a glomus tumor from a high-placed jugular bulb. **Analysis of Options:** * **Glomus Tumor (Correct):** These are highly vascular paragangliomas. The Phelps sign indicates the destructive nature of the tumor as it expands from the jugular bulb toward the carotid artery. * **Otosclerosis:** Characterized by the **Schwartze sign** (flamingo flush) on otoscopy and the **Carhart’s notch** at 2 kHz on audiometry. It involves bony remodeling, not large-scale erosion of the jugular crest. * **Meniere’s Disease:** A clinical diagnosis of endolymphatic hydrops. It does not present with bony erosive signs on imaging. * **Lateral Sinus Thrombosis:** A complication of CSOM characterized by the **Griesinger sign** (edema over the mastoid) and the **Delta sign** (empty triangle) on contrast CT, representing a thrombus in the sinus. **NEET-PG High-Yield Pearls for Glomus Tumor:** 1. **Brown’s Sign:** Pulsation of the tympanic membrane seen on otoscopy, which ceases with positive pressure (Siegle’s bulb). 2. **Aquino’s Sign:** Blanching of the tympanic mass upon carotid artery compression. 3. **Clinical Presentation:** Pulsatile tinnitus (most common symptom) and a "rising sun" appearance behind the intact eardrum. 4. **Investigation of Choice:** Contrast-enhanced MRI (shows "salt and pepper" appearance).

Question 34: The stapes foot plate covers which anatomical structure?

A. Round window
B. Oval window (Correct Answer)
C. Sinus tympani
D. Pyramid

Explanation: **Explanation:** The middle ear functions as an impedance-matching mechanism, transmitting sound vibrations from the air to the fluid-filled cochlea. The **stapes**, the smallest bone in the human body, consists of a head, neck, two crura, and a **footplate**. The footplate is held in the **Oval Window** (Fenestra vestibuli) by the annular ligament. When the stapes vibrates, it pushes the footplate into the oval window, creating pressure waves in the perilymph of the scala vestibuli. **Analysis of Options:** * **A. Round Window (Fenestra Cochleae):** This is located postero-inferior to the oval window and is covered by the **secondary tympanic membrane**. It serves as a pressure release valve; as the stapes pushes into the oval window, the round window membrane bulges outward. * **C. Sinus Tympani:** This is a deep recession on the posterior wall of the tympanic cavity, medial to the pyramid and facial nerve canal. It is a clinically significant site as it is a common hiding spot for **cholesteatoma**. * **D. Pyramid:** This is a hollow conical projection on the posterior wall that houses the **stapedius muscle**. The tendon of the stapedius emerges from its apex to attach to the neck of the stapes. **High-Yield Clinical Pearls for NEET-PG:** * **Otosclerosis:** A condition characterized by pathological bone remodeling that fixes the stapes footplate in the oval window, leading to conductive hearing loss. * **Schwartze Sign:** A flamingo-pink flush seen on the promontory through the TM, indicative of active otosclerosis. * **Stapedectomy:** The surgical treatment for otosclerosis where the fixed footplate is bypassed or removed and replaced with a prosthesis.

Question 35: A 3-year-old girl ruptured her eardrum when she inserted a pencil into her external ear canal. She was urgently admitted to the emergency department. Physical examination revealed pain in her ear and a few drops of blood in the external auditory meatus. There was concern that there might possibly have been an injury to the nerve that principally innervates the external surface of the tympanic membrane. Which of the following tests is most likely to be performed during physical examination to check for injury to this nerve?

A. Check the taste in the anterior two thirds of the tongue.
B. Check the sensation to the pharynx and palate.
C. Check if there is paraesthesia at the TMJ. (Correct Answer)
D. Check for sensation in the larynx.

Explanation: **Explanation:** The core of this question lies in understanding the sensory innervation of the external ear and the tympanic membrane (TM). **1. Why Option C is Correct:** The external surface of the tympanic membrane is principally innervated by the **Auriculotemporal nerve** (a branch of the Mandibular division of the Trigeminal nerve, V3), with a smaller contribution from the Auricular branch of the Vagus (Arnold’s nerve). The Auriculotemporal nerve also provides sensory innervation to the **Temporomandibular Joint (TMJ)** and the skin of the temple. Therefore, if the nerve supplying the TM is injured, clinical testing for paresthesia or sensory loss over the TMJ region is the most logical step to assess its integrity. **2. Why Other Options are Incorrect:** * **Option A:** Taste in the anterior 2/3 of the tongue is carried by the **Chorda Tympani** (branch of CN VII). While it runs across the medial surface of the TM, it does not innervate the external surface of the drum. * **Option B:** Sensation to the pharynx and palate is primarily mediated by the **Glossopharyngeal (CN IX)** and **Vagus (CN X)** nerves. CN IX supplies the *inner* (medial) surface of the TM via the Jacobson’s nerve, not the external surface. * **Option D:** Sensation in the larynx is provided by the **Internal Laryngeal nerve** (branch of CN X). While the Vagus does have an auricular branch, testing the larynx is not a standard or practical way to assess localized trauma to the external ear canal. **Clinical Pearls for NEET-PG:** * **Innervation of TM:** External surface (V3 > X > VII); Internal surface (IX). * **Hilton’s Law:** A nerve supplying a joint also tends to supply the muscles moving the joint and the skin over the insertion of those muscles. This explains why V3 supplies both the TMJ and the adjacent ear structures. * **Reflex Cough:** Irritation of the external canal (Vagus nerve) can trigger a cough reflex (Arnold’s reflex).

Question 36: Hypoacusis is caused by paralysis of which of the following muscles?

A. Mylohyoid
B. Tensor tympani (Correct Answer)
C. Tensor veli palatini
D. Macula densa

Explanation: **Explanation:** **1. Why Tensor Tympani is Correct:** The **Tensor tympani** muscle is located in the middle ear and is supplied by the **Mandibular nerve (V3)**. Its primary function is to increase the tension of the tympanic membrane by pulling the handle of the malleus medially. This action stiffens the ossicular chain, reducing the vibration amplitude in response to loud noises (the attenuation reflex). Paralysis of this muscle leads to a loss of this tensioning effect, resulting in decreased sound conduction efficiency or abnormal sound perception, clinically manifesting as **hypoacusis** (reduced hearing) or occasionally hyperacusis. **2. Why Other Options are Incorrect:** * **Mylohyoid:** This muscle forms the floor of the mouth and is involved in deglutition and elevation of the hyoid bone. It has no role in the auditory mechanism. * **Tensor Veli Palatini:** While also supplied by V3, this muscle functions to open the **Eustachian tube** during swallowing. While its dysfunction can lead to middle ear effusion (causing hearing loss), the muscle itself does not directly control the tension of the tympanic membrane. * **Macula Densa:** This is a collection of specialized cells in the **distal convoluted tubule** of the kidney that sense sodium chloride concentration; it is entirely unrelated to the ear. **Clinical Pearls for NEET-PG:** * **Stapedius vs. Tensor Tympani:** The Stapedius (supplied by the **Facial nerve**) is the more clinically significant muscle. Its paralysis (e.g., in Bell’s Palsy) typically causes **Hyperacusis** (intolerance to loud sounds) because the dampening effect on the stapes is lost. * **Innervation Rule:** Remember that muscles with "Tensor" in their name (Tensor tympani, Tensor veli palatini) are generally supplied by the **Trigeminal nerve (V3)**. * **Reflex:** The acoustic reflex primarily involves the stapedius muscle in humans, but the tensor tympani responds to startle responses and non-acoustic stimuli (e.g., puff of air to the eye).

Question 37: Greisinger's sign is suggestive of:

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

Explanation: ### Explanation **Greisinger’s sign** is a classic clinical finding in **Lateral Sinus Thrombosis (LST)**, which is a serious extracranial complication of chronic or acute coalescent mastoiditis. #### 1. Why Option A is Correct The sign refers to **pitting edema and tenderness over the mastoid process**, specifically over the area of the mastoid emissary vein. * **Pathophysiology:** When the lateral (sigmoid) sinus becomes thrombosed, the retrograde pressure causes thrombosis or congestion of the **mastoid emissary vein**. This leads to localized edema and inflammatory changes in the soft tissues behind the mastoid. * In the context of the NEET-PG, this is a high-yield association with "Hectic Pick-fence" fever and the Griesinger sign. #### 2. Why Other Options are Incorrect * **Option B:** Maxillary cancer spreading to the nasal cavity presents with cheek swelling, epistaxis, or infraorbital anesthesia, but does not involve mastoid edema. * **Option C:** Rhinosporidiosis is a granulomatous fungal-like infection (caused by *Rhinosporidium seeberi*) characterized by leafy, strawberry-like nasal masses; it has no relation to venous thrombosis. * **Option D:** While LST can lead to internal jugular vein (IJV) thrombosis, the specific sign for IJV involvement is a palpable "cord-like" swelling in the neck, not mastoid edema. #### 3. Clinical Pearls for NEET-PG * **Tobey-Ayer Test / Queckenstedt’s Test:** Used during lumbar puncture to diagnose LST. Compression of the IJV on the affected side fails to show a rise in CSF pressure. * **Crowe-Beck Test:** Engorgement of retinal veins and conjunctiva upon compressing the IJV on the healthy side. * **Delta Sign (Empty Triangle Sign):** Seen on contrast-enhanced CT, representing a clot in the sigmoid sinus surrounded by dural enhancement. * **Treatment:** High-dose antibiotics, mastoidectomy, and potentially anticoagulants.

Question 38: 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 and slowly progressive. Pure tone audiometry shows 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 **1. Why Otosclerosis is the Correct Answer:** The clinical presentation is classic for **Otosclerosis**, a primary metabolic bone disease of the otic capsule. * **Epidemiology:** It typically affects young adults (20–30 years) and has a strong **autosomal dominant** inheritance with incomplete penetrance (family history). * **Pregnancy:** Hormonal changes during pregnancy are known to accelerate the progression of the disease. * **Audiometry:** The "apparent bone conduction loss at 2000 Hz" is the pathognomonic **Carhart’s Notch**. This is not a true sensorineural loss but a mechanical artifact caused by the loss of the stapes' resonance frequency (normally 2000 Hz) due to stapedial fixation. **2. Why Other Options are Incorrect:** * **Acoustic Neuroma:** This presents with unilateral sensorineural hearing loss and tinnitus, not bilateral conductive loss triggered by pregnancy. * **Otitis Media with Effusion (OME):** While it causes conductive hearing loss, it is usually associated with Eustachian tube dysfunction or URTI and would show a "B" type tympanogram, not Carhart’s notch. * **Sigmoid Sinus Thrombosis:** This is a complication of chronic suppurative otitis media (CSOM) presenting with "picket-fence" fever and headache, not progressive hearing loss. **3. High-Yield Clinical Pearls for NEET-PG:** * **Schwartz Sign:** A flamingo-pink flush seen on the promontory through the TM (indicates active disease/otospongiosis). * **Gelle’s Test:** Negative (indicates stapes fixation). * **Tympanometry:** Typically shows an **As type** curve (stiffened ossicular chain). * **Treatment of Choice:** **Stapedotomy** (with Teflon piston insertion). Sodium fluoride can be used to medically manage the active phase.

Question 39: Otomycosis is caused by which of the following organisms?

A. Candida
B. Aspergillus
C. Both Candida and Aspergillus (Correct Answer)
D. None of the above

Explanation: **Explanation:** **Otomycosis** (also known as "Singapore Ear" or Tropical Ear) is a fungal infection of the external auditory canal. It is most commonly seen in hot, humid climates or in patients who frequently use topical antibiotic ear drops, which disrupt the normal bacterial flora. **Why Option C is Correct:** The etiology of Otomycosis is predominantly fungal, involving two main genera: 1. **Aspergillus:** This is the most common cause (80-90% of cases). Specifically, *Aspergillus niger* is classic for producing black, soot-like spores, while *Aspergillus fumigatus* produces pale blue or green spores. 2. **Candida:** *Candida albicans* is the second most frequent pathogen. It typically presents as a white, creamy, curd-like discharge. Since both organisms are primary causative agents, **Option C** is the most accurate choice. **Analysis of Incorrect Options:** * **Options A and B:** While both Candida and Aspergillus cause Otomycosis, selecting one over the other would be incomplete, as clinical studies show both are frequently isolated from infected ears. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Intense itching (pruritus), ear pain (otalgia), and a "wet newspaper" appearance of the debris in the canal. * **Characteristic Morphology:** On otoscopy, *A. niger* looks like a "conidial head" or a "wet piece of filter paper with black dots." * **Treatment:** The mainstay of treatment is **thorough aural toilet** (cleaning the debris) followed by topical antifungal agents like **Clotrimazole** (most common), Nystatin, or Povidone-iodine. * **Risk Factors:** Excessive moisture (swimming), immunocompromised states (Diabetes Mellitus), and prolonged use of topical steroids/antibiotics.

Question 40: What is tympanoplasty?

A. Eradication of middle ear disease with reconstruction of the tympanic membrane and ossicles (Correct Answer)
B. Eradication of disease from the internal ear
C. Repair of the tympanic membrane only
D. Repair of the ossicle only

Explanation: **Explanation:** **Tympanoplasty** is defined as a surgical procedure performed to eradicate disease from the middle ear and to reconstruct the hearing mechanism, with or without grafting of the tympanic membrane (TM). According to Wullstein’s classification, it encompasses both the repair of the TM and the restoration of the ossicular chain to improve conductive hearing loss. * **Why Option A is correct:** The core objective of tympanoplasty is twofold: **clearance** (removing pathology like cholesteatoma or granulation tissue) and **reconstruction** (restoring the TM and/or ossicles). * **Why Option B is incorrect:** Surgery on the internal ear (cochlea/vestibule) involves procedures like labyrinthectomy or cochlear implantation, not tympanoplasty. * **Why Option C is incorrect:** Repair of the tympanic membrane *only* is specifically termed **Myringoplasty**. While myringoplasty is a type of tympanoplasty (Wullstein Type I), the term "Tympanoplasty" is broader. * **Why Option D is incorrect:** Repair of the ossicular chain *only* is termed **Ossiculoplasty**. **High-Yield Clinical Pearls for NEET-PG:** * **Wullstein Classification:** * **Type I:** Only TM repair (Myringoplasty). * **Type II:** TM repair + Malleus handle erosion (graft placed on incus). * **Type III (Myringostapedopexy):** Graft placed directly on the stapes head (columella effect). * **Type IV:** Graft placed on stapes footplate. * **Type V:** Fenestration of the lateral semicircular canal. * **Graft Materials:** Temporalis fascia is the most common (Gold Standard) due to its low metabolic rate and proximity to the incision. * **Prerequisite:** The Eustachian tube must be functional for a successful tympanoplasty outcome.

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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

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Implantable Hearing Devices

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Congenital Aural Atresia

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Otologic Trauma

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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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