Stapedectomy — MCQs
A female patient's pure tone audiometry (PTA) findings show the presence of a Carhart's notch. Which of the following specific clinical signs can be seen in this patient?
Most common bone affected by otosclerosis?
A 45-year-old gentleman reports decreased hearing in the right ear for the last two years. On testing with a 512 Hz tuning fork, the Rinne's test without masking is negative on the right ear and positive on the left ear. With the Weber's test, the tone is perceived as louder in the left ear. Patient most likely has -
Carhart's notch in audiometry is seen in -
Iatrogenic traumatic facial nerve palsy is MOST commonly produced during which of the following surgical procedures?
Most common cause of sensorineural hearing loss (SNHL)
Rinne's test was negative in the right ear. What is the possible diagnosis?
Which of the following is the most common morbidity associated with Meniere's disease?
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?
Gelle's test is done in?
Stapedectomy Indian Medical PG Practice Questions and MCQs
Question 1: A female patient's pure tone audiometry (PTA) findings show the presence of a Carhart's notch. Which of the following specific clinical signs can be seen in this patient?
- A. Schwartz sign (Correct Answer)
- B. Hitselberger sign
- C. Hennebert sign
- D. Rinne test negative (conductive hearing loss)
Explanation: ***Schwartz sign*** - A **Carhart's notch** (bone conduction dip at 2000 Hz) is a characteristic finding in **otosclerosis**, a condition where the stapes bone becomes fixed. - The **Schwartz sign** (reddish/pinkish hue behind the tympanic membrane) indicates **active otosclerosis** with increased vascularity in the promontory. - This is a **specific clinical sign** directly associated with otosclerosis and would be the expected finding on otoscopy. *Hitselberger sign* - The **Hitselberger sign** refers to **hypesthesia** (numbness or decreased sensation) in the **posterior external auditory canal wall**. - It is associated with **acoustic neuromas** (vestibular schwannomas) due to compression of the facial nerve, not otosclerosis. *Hennebert sign* - The **Hennebert sign** involves **nystagmus or vertigo** induced by changes in external ear canal pressure (fistula test). - It is typically seen in conditions causing a **perilymphatic fistula**, such as **Meniere's disease** or **syphilitic labyrinthitis**, not otosclerosis. *Rinne test negative (conductive hearing loss)* - While otosclerosis does cause **conductive hearing loss** with a negative Rinne test (bone conduction > air conduction), this is a **general audiometric finding**, not a specific clinical sign. - A negative Rinne test can occur in **any cause of conductive hearing loss** (chronic otitis media, ossicular discontinuity, cholesteatoma, etc.). - The question asks for a **specific clinical sign**, making the **Schwartz sign** the most appropriate answer as it specifically indicates otosclerosis.
Question 2: Most common bone affected by otosclerosis?
- A. Stapes (Correct Answer)
- B. Bony labyrinth
- C. Mastoid process
- D. Incus
Explanation: ***Stapes*** - **Otosclerosis** is characterized by abnormal bone remodeling in the otic capsule, primarily affecting the **stapes footplate**. - This leads to its fixation in the oval window, causing **conductive hearing loss**. - The **stapediovestibular joint** is the most common site, occurring in over 90% of cases. *Bony labyrinth* - While otosclerosis originates in the **otic capsule** (which forms the bony labyrinth), the term refers to a broader anatomical structure. - The specific site of clinical significance is the **stapes footplate**, not the labyrinth as a whole. *Mastoid process* - The **mastoid process** is part of the temporal bone but is structurally distinct from the middle ear and otic capsule. - It is not involved in otosclerosis pathology. *Incus* - While the **incus** is a middle ear ossicle, it is rarely affected by otosclerosis. - The disease process specifically targets the **stapes footplate** at the oval window, not other ossicles.
Question 3: A 45-year-old gentleman reports decreased hearing in the right ear for the last two years. On testing with a 512 Hz tuning fork, the Rinne's test without masking is negative on the right ear and positive on the left ear. With the Weber's test, the tone is perceived as louder in the left ear. Patient most likely has -
- A. Right conductive hearing loss (Correct Answer)
- B. Right sensorineural hearing loss
- C. Left sensorineural hearing loss
- D. Left conductive hearing loss
Explanation: ***Right conductive hearing loss*** - A **negative Rinne's test** (bone conduction louder than air conduction) in the right ear indicates **conductive hearing loss** on that side - However, in true conductive hearing loss, **Weber should lateralize to the affected (right) ear** due to the occlusion effect, not to the left ear - The Weber lateralizing to the left ear with a negative Rinne on the right suggests this may be a **false negative Rinne** due to lack of masking, where sound crosses over to the better left ear - This combination is atypical for pure conductive loss and requires repeat testing with proper masking *Right sensorineural hearing loss* - In **sensorineural hearing loss**, Rinne's test should be **positive** (air conduction > bone conduction) on both sides, though both may be reduced on the affected side - **Weber lateralizes to the unaffected (left) ear**, which matches the given finding - The **negative Rinne on the right ear without masking** is likely a **false negative** due to sound crossing over to the better left ear during bone conduction testing - This is the **most consistent interpretation** when Rinne testing is done without masking, but traditionally the question frame suggests conductive loss *Left sensorineural hearing loss* - Would show **positive Rinne bilaterally** with reduced hearing on the left - **Weber would lateralize to the right ear** (the better ear), contradicting the given findings - This option is clearly inconsistent with the clinical findings *Left conductive hearing loss* - Would show **negative Rinne on the left** and positive on the right - Weber would lateralize to the left ear (affected side in conductive loss) - The **Rinne findings contradict this**, as the right ear shows negative Rinne, not the left
Question 4: Carhart's notch in audiometry is seen in -
- A. Ossicular discontinuity
- B. Otosclerosis (Correct Answer)
- C. Otomycosis
- D. Haemotympanum
Explanation: ***Otosclerosis*** - **Carhart's notch** is a characteristic dip in the **bone conduction threshold** at 2000 Hz, typically observed in patients with **otosclerosis**. - This phenomenon is believed to be due to an artifact caused by the **stapes fixation** interfering with the normal inertial and compressional bone conduction mechanisms. *Ossicular discontinuity* - While ossicular discontinuity causes a **conductive hearing loss**, it typically does not present with a specific notch at 2000 Hz in bone conduction. - The audiogram would show a significant **air-bone gap** but without the characteristic bone conduction dip. *Otomycosis* - **Otomycosis** is a fungal infection of the external auditory canal and can cause **conductive hearing loss** if there is significant debris or swelling. - It does not, however, lead to a Carhart's notch on the audiogram. *Haemotympanum* - **Haemotympanum**, or blood behind the tympanic membrane, causes a **conductive hearing loss** by dampening the movement of the tympanic membrane and ossicles. - This condition results in a **flat or low-frequency conductive hearing loss** without the specific audiometric feature of Carhart's notch.
Question 5: Iatrogenic traumatic facial nerve palsy is MOST commonly produced during which of the following surgical procedures?
- A. Ossiculoplasty
- B. Myringoplasty
- C. Mastoidectomy (Correct Answer)
- D. Stapedectomy
Explanation: ***Mastoidectomy*** - **Mastoidectomy** involves extensive bone removal around the **facial nerve's mastoid segment**, making it the most vulnerable during this procedure due to its complex anatomical course. - The surgery's depth and proximity to the fallopian canal increase the risk of accidental nerve injury from drilling or instrumentation. *Ossiculoplasty* - **Ossiculoplasty** primarily involves repairing or replacing the **ossicles** in the middle ear, generally not requiring manipulation close to the facial nerve. - While the nerve is in the vicinity, direct trauma is rare compared to extensive bone work. *Myringoplasty* - **Myringoplasty** is a relatively superficial procedure involving the repair of the **tympanic membrane**, far from the main course of the facial nerve. - The surgical field is typically limited to the external auditory canal and middle ear cavity, posing minimal risk to the nerve. *Stapedectomy* - **Stapedectomy** involves operating on the **stapes bone** in the oval window, which is near the horizontal segment of the facial nerve, but less frequently injured compared to mastoid surgery. - Although the nerve is identified and protected, the extent of bone removal and proximity is less than in a full mastoidectomy.
Question 6: Most common cause of sensorineural hearing loss (SNHL)
- A. Labyrinthitis
- B. Meniere's disease
- C. Presbycusis (Correct Answer)
- D. Vestibular Schwannoma
Explanation: ***Presbycusis*** - **Presbycusis**, or age-related hearing loss, is the most common cause of **sensorineural hearing loss (SNHL)**, affecting a significant portion of the elderly population. - It typically results from **degenerative changes** in the inner ear, specifically the hair cells and nerve fibers, leading to a gradual, symmetrical, high-frequency SNHL. *Labyrinthitis* - **Labyrinthitis** is an inflammation of the inner ear that can cause sudden SNHL, often accompanied by **vertigo** and **tinnitus**. - While it causes SNHL, it is an acute condition and not the most common overall cause, especially when considering the prevalence of age-related hearing loss. *Meniere's disease* - **Meniere's disease** is characterized by recurrent episodes of **vertigo, fluctuating low-frequency SNHL, tinnitus**, and aural fullness. - It is a specific condition causing SNHL, but its prevalence is much lower than presbycusis, making it a less common overall cause. *Vestibular Schwannoma* - A **vestibular schwannoma** (acoustic neuroma) is a benign tumor that arises from the Schwann cells of the **vestibulocochlear nerve**. - It can cause **progressive unilateral SNHL**, tinnitus, and balance issues, but it is a relatively rare condition compared to presbycusis.
Question 7: Rinne's test was negative in the right ear. What is the possible diagnosis?
- A. Profound hearing loss right ear, left ear normal
- B. 40 dB CHL in both ears
- C. 40 dB SNHL in left ear, right ear normal
- D. 40 dB CHL right ear, left normal (Correct Answer)
Explanation: ***40 dB CHL right ear, left normal*** - A **negative Rinne's test** indicates that **bone conduction is better than air conduction**, which is characteristic of a **conductive hearing loss (CHL)** in the tested ear. - For Rinne's test to be negative, the conductive hearing loss usually needs to be at least **25-30 dB**, making **40 dB CHL** a plausible diagnosis. - This correctly identifies the **right ear** as the affected ear with conductive pathology. *40 dB SNHL in left ear, right ear normal* - A **negative Rinne's test** in the **right ear** means the issue is in the right ear, not the left. - **Sensorineural hearing loss (SNHL)** typically results in a **positive Rinne's test** (air conduction better than bone conduction) as both air and bone conduction are equally reduced. - This option incorrectly identifies the left ear and wrong type of hearing loss. *40 dB CHL in both ears* - While a negative Rinne's test indicates CHL, it specifically points to the ear being tested (the **right ear** in this case). - There is no information from a unilateral Rinne's test to suggest CHL in the **left ear** as well. - This represents over-interpretation of a unilateral test finding. *Profound hearing loss right ear, left ear normal* - A **profound hearing loss** (particularly severe SNHL) in the right ear could result in a false-negative Rinne's test where bone conduction is picked up by the contralateral ear. - However, a negative Rinne's test without additional context more specifically indicates **moderate conductive hearing loss (40 dB CHL)** rather than profound loss. - The term "profound" is also imprecise without specifying the type of hearing loss.
Question 8: Which of the following is the most common morbidity associated with Meniere's disease?
- A. Permanent hearing loss (Correct Answer)
- B. Secondary development of a craniopharyngioma
- C. Chronic otitis media
- D. Chronic otitis externa
Explanation: ***Permanent hearing loss*** - **Meniere's disease** is characterized by episodes of **vertigo**, **tinnitus**, ear fullness, and fluctuating hearing loss, which often progresses to permanent hearing loss over time. - The recurrent episodes of **endolymphatic hydrops** cause cumulative damage to the **cochlea** and **vestibular apparatus**, leading to irreversible sensorineural hearing loss. *Chronic otitis media* - This is an **infection** and **inflammation of the middle ear**, typically leading to tympanic membrane perforation or cholesteatoma. - It is distinct from Meniere's disease, which is a disorder of the **inner ear** with no direct pathological link to middle ear infections. *Chronic otitis externa* - This condition involves **inflammation of the external ear canal** and is usually caused by bacterial or fungal infections. - It is an outer ear condition and bears no etiological or symptomatic relationship to the inner ear pathology of Meniere's disease. *Secondary development of a craniopharyngioma* - A **craniopharyngioma** is a benign brain tumor arising from Rathke's pouch cells, typically located near the **pituitary gland**. - There is no known direct association or increased risk of developing a craniopharyngioma in patients with Meniere's disease.
Question 9: 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 10: Gelle's test is done in?
- A. Traumatic deafness
- B. Senile deafness
- C. Otosclerosis (Correct Answer)
- D. Serous otitis media
Explanation: ***Otosclerosis*** - **Gelle's test** is primarily used to diagnose **otosclerosis**, a condition causing **conductive hearing loss** due to abnormal bone growth in the middle ear. - The test assesses changes in **bone conduction hearing** in response to alterations in external ear canal pressure, which is characteristic of a fixed stapes footplate in otosclerosis. *Traumatic deafness* - **Traumatic deafness** can result from direct injury to the ear, but **Gelle's test** is not a primary diagnostic tool for this type of hearing loss. - Diagnosis typically involves evaluating the **nature and extent of the trauma** and other audiometric tests. *Senile deafness* - Also known as **presbycusis**, **senile deafness** is a **sensorineural hearing loss** associated with aging. - **Gelle's test** assesses changes in bone conduction with pressure, making it less relevant for diagnosing age-related nerve damage. *Serous otitis media* - **Serous otitis media** involves fluid accumulation in the middle ear, leading to **conductive hearing loss**. - While it causes conductive hearing loss, **Gelle's test** is not the definitive diagnostic test; **tympanometry** and **audiometry** are more commonly used.
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