Tympanic Membrane Perforation — MCQs
A 65-year-old patient presents with gradual progressive hearing loss over several years. Rinne test shows bone conduction > air conduction bilaterally. Weber test lateralizes to the worse ear. Tympanic membranes are intact and normal. Which is the most likely diagnosis?
Bilateral Rinne test +ve and Weber test lateralized to right with a shortened Schwabach test on left side suggests ?
A 5-year-old boy has been diagnosed with a posterior superior retraction pocket. Which of the following would constitute part of the management?
Fenestration operation is which type of tympanoplasty?
The preferred site of incision for myringotomy in ASOM (Acute Suppurative Otitis Media) to drain the middle ear is:
Carhart's notch in audiometry is seen in -
All of the following are features of Tubotympanic CSOM except which of the following?
What is the primary purpose of the Bing test in audiology?
Which of the following statements about tubercular otitis media is false?
Rosen's incision is used for which surgical procedure?
Tympanic Membrane Perforation Indian Medical PG Practice Questions and MCQs
Question 1: A 65-year-old patient presents with gradual progressive hearing loss over several years. Rinne test shows bone conduction > air conduction bilaterally. Weber test lateralizes to the worse ear. Tympanic membranes are intact and normal. Which is the most likely diagnosis?
- A. Acoustic neuroma
- B. Cerumen impaction
- C. Otosclerosis (Correct Answer)
- D. Cholesteatoma
Explanation: ***Otosclerosis*** - **Otosclerosis** is characterized by abnormal bone remodeling in the otic capsule, leading to **stapes fixation** at the oval window - Classic presentation: **progressive bilateral conductive hearing loss** in adults (typically 20-40 years) - **Rinne negative** (bone conduction > air conduction) and **Weber lateralizes to worse ear** confirm conductive hearing loss - **Carhart notch** (bone conduction dip at 2000 Hz) is pathognomonic on audiometry - Tympanic membrane appears **normal** - key differentiating feature *Cerumen impaction* - Would cause conductive hearing loss but presents with **visible earwax obstruction** on otoscopy - Typically **acute onset**, not gradual progressive loss over years - Easily identified and removed during examination - Does not match the clinical picture of intact, normal tympanic membranes with chronic progressive bilateral loss *Acoustic neuroma* - Causes **sensorineural hearing loss**, not conductive - **Rinne would be positive** (air conduction > bone conduction) in both ears - Typically **unilateral** hearing loss with associated tinnitus and possible vestibular symptoms - Weber lateralizes to the **better ear** in sensorineural loss *Cholesteatoma* - Causes conductive hearing loss but presents with **abnormal tympanic membrane** findings - Typically shows **whitish mass visible behind or within the tympanic membrane** - Often associated with **chronic ear discharge** and history of chronic otitis media - Usually **unilateral** presentation - Does not match the description of intact, normal tympanic membranes bilaterally
Question 2: Bilateral Rinne test +ve and Weber test lateralized to right with a shortened Schwabach test on left side suggests ?
- A. Right middle ear pathology
- B. Right inner ear pathology
- C. Left middle ear pathology
- D. Left inner ear pathology (Correct Answer)
Explanation: ***Left inner ear pathology*** - A **bilateral positive Rinne test** indicates that **air conduction is better than bone conduction** in both ears, which is either normal or suggests **sensorineural hearing loss** (rules out conductive loss). - **Weber test lateralizing to the right** means sound is heard better in the right ear, indicating **left ear pathology**. Combined with positive Rinne bilaterally, this confirms **left sensorineural hearing loss**. - A **shortened Schwabach test on the left side** means **bone conduction duration is reduced** compared to normal, directly confirming **sensorineural hearing loss** in the left ear. *Right middle ear pathology* - A **conductive hearing loss** on the right would cause a **negative Rinne test** on the right side (bone conduction better than air conduction), contradicting the bilateral positive Rinne findings. - While **Weber would lateralize to the right** with right conductive loss, the **positive Rinne bilaterally** rules out any significant conductive pathology. *Right inner ear pathology* - A **sensorineural hearing loss** on the right would cause Weber test to **lateralize to the better (left) ear**, not to the right as described in the question. - The **shortened Schwabach test is on the left side**, not the right, indicating left ear pathology rather than right inner ear involvement. *Left middle ear pathology* - A **conductive hearing loss** in the left ear would cause a **negative Rinne test on the left side** (bone conduction better than air conduction), contradicting the bilateral positive findings. - **Weber test would lateralize to the left ear** (affected ear with conductive loss), not to the right as stated in the question.
Question 3: A 5-year-old boy has been diagnosed with a posterior superior retraction pocket. Which of the following would constitute part of the management?
- A. Audiometry (Correct Answer)
- B. Mastoid exploration
- C. Tympanoplasty
- D. Cholesteatoma removal through mastoid exploration
Explanation: ***Audiometry*** - A **posterior superior retraction pocket** can lead to **ossicular erosion** and **conductive hearing loss**. Prior to any intervention, a **baseline audiogram** is essential to assess the degree of hearing impairment. - Regular **audiometric monitoring** helps track the progression of hearing loss and the effectiveness of management strategies. *Mastoid exploration* - **Mastoid exploration** is an invasive surgical procedure primarily performed for **cholesteatoma removal** or significant **mastoid infection**. - A simple retraction pocket alone, without evidence of cholesteatoma or significant complications, typically does not warrant immediate mastoid exploration. *Tympanoplasty* - **Tympanoplasty** is a surgical procedure to repair a **perforated eardrum** or reconstruct the **ossicular chain**. - While a severely retracted pocket might eventually lead to a perforation or ossicular damage, the initial management of a simple retraction pocket does not typically start with tympanoplasty; observation and audiometric monitoring are usually the first steps. *Cholesteatoma removal through mastoid exploration* - This option describes a treatment for **cholesteatoma**, a destructive lesion often associated with retraction pockets. - While a **posterior superior retraction pocket** is a risk factor for cholesteatoma development, the question states a "retraction pocket" has been diagnosed, not explicitly a cholesteatoma. Therefore, the immediate management focuses on monitoring and confirming the absence of cholesteatoma. If cholesteatoma develops, then this surgical approach would be considered.
Question 4: Fenestration operation is which type of tympanoplasty?
- A. Type-3
- B. Type-2
- C. Type-4
- D. Type-5 (Correct Answer)
Explanation: ***Type-5*** - **Fenestration operation** is classified as **Type V tympanoplasty** in Wullstein's classification. - This procedure creates a **new fenestra (window) in the lateral semicircular canal** to bypass a fixed oval window/stapes in cases of **otosclerosis**. - Sound waves are directed to this new window, bypassing the immobile stapes footplate. - Historically important procedure before **stapedectomy** became the standard treatment for otosclerosis. *Type-2* - **Type II tympanoplasty** involves repair with a **partially eroded malleus** where the graft is placed onto the **incus or remaining malleus**. - Requires an intact and mobile stapes, unlike fenestration which bypasses a fixed stapes. - Used for tympanic membrane perforations with minor ossicular damage. *Type-3* - **Type III tympanoplasty** involves placing the graft directly onto the **stapes head** (columella effect). - Performed when malleus and incus are eroded but stapes is intact and mobile. - This is **myringostapediopexy**, not fenestration. *Type-4* - **Type IV tympanoplasty** involves creating a **small middle ear cavity** with the graft placed over the **round window**. - Used when the stapes arch is absent but the footplate is mobile. - Different from fenestration as it utilizes the round window, not a semicircular canal fenestra.
Question 5: The preferred site of incision for myringotomy in ASOM (Acute Suppurative Otitis Media) to drain the middle ear is:
- A. Anteroinferior
- B. Posteroinferior (Correct Answer)
- C. Anterosuperior
- D. Posterosuperior
Explanation: ***Posteroinferior*** - The **posteroinferior quadrant** of the tympanic membrane is the preferred site for myringotomy in **acute suppurative otitis media (ASOM)** due to its relative avascularity and safety regarding middle ear structures. - This location allows for adequate drainage of pus and prevents re-accumulation, without damaging essential structures like the **ossicular chain** or the **facial nerve**. *Anteroinferior* - This quadrant is generally avoided because it provides less effective drainage and carries a higher risk of injury to the **Eustachian tube orifice** or other anterior structures. - The **handle of the malleus** runs posteriorly, and an incision here might be less effective for gravity-assisted drainage. *Anterosuperior* - The **anterosuperior quadrant** is not typically chosen due to its proximity to the **ossicular chain** attachments and potentially larger blood vessels, increasing the risk of bleeding and injury. - Incisions in this region are often less effective for draining fluids that tend to collect in the more dependent parts of the middle ear. *Posterosuperior* - While somewhat accessible, the **posterosuperior quadrant** carries a higher risk of damaging the **incus** and **stapes**, as well as the **facial nerve** or **chorda tympani nerve**. - Its elevated position also makes it less ideal for gravity-dependent drainage of purulent fluid from the middle ear.
Question 6: 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 7: All of the following are features of Tubotympanic CSOM except which of the following?
- A. Profuse discharge
- B. Hearing loss
- C. Extreme pain (Correct Answer)
- D. Facial nerve paralysis
Explanation: ***Extreme pain*** - **Extreme pain** is NOT a characteristic feature of **tubotympanic CSOM**. This type is typically associated with a history of **painless otorrhea**. - Tubotympanic CSOM is considered the "safe" type with inflammation limited to the mucosa without bone erosion. - The presence of severe pain should raise suspicion for complications or the **atticoantral (unsafe) type** of CSOM. *Profuse discharge* - **Profuse, mucoid** or **mucopurulent discharge** is a hallmark feature of tubotympanic CSOM. - This discharge results from chronic inflammation of the **middle ear mucoperiosteum** through a central perforation in the **pars tensa**. - The discharge is typically non-foul smelling (unlike atticoantral CSOM). *Hearing loss* - **Conductive hearing loss** is a universal feature of tubotympanic CSOM. - Results from **tympanic membrane perforation**, middle ear effusion, and potential ossicular discontinuity. - The degree of hearing loss correlates with the size and location of the perforation. *Facial nerve paralysis* - Facial nerve paralysis is **NOT a typical feature** of tubotympanic (safe) CSOM. - This complication is characteristically associated with **atticoantral (unsafe) CSOM** with cholesteatoma causing bone erosion. - While theoretically possible in very advanced neglected tubotympanic disease, it would indicate transformation to unsafe disease or secondary complications. - **Note:** Some sources may list this as a rare complication, but it is not a characteristic feature distinguishing tubotympanic CSOM, making this option potentially ambiguous in an "EXCEPT" question format.
Question 8: What is the primary purpose of the Bing test in audiology?
- A. Assessing overall hearing ability through audiometry
- B. Evaluating sound conduction through air
- C. A general term for various hearing assessments
- D. Determining the effect of ear canal occlusion on sound conduction (Correct Answer)
Explanation: ***Determining the effect of ear canal occlusion on sound conduction*** - The Bing test specifically assesses how **occluding the ear canal** (using a finger or probe) affects the perception of **bone-conducted sound** from a tuning fork placed on the mastoid. - This test evaluates the **occlusion effect**, which is the increase in loudness of bone-conducted sound when the ear canal is occluded. - In **normal hearing** or **sensorineural hearing loss**, occluding the ear canal makes the bone-conducted sound louder (positive Bing test). - In **conductive hearing loss**, there is no change or the sound becomes softer (negative Bing test), as the conductive pathology already creates an occlusion-like effect. - This helps differentiate between **conductive** and **sensorineural hearing loss**. *Assessing overall hearing ability through audiometry* - **Audiometry** is a broad term encompassing various tests to quantify hearing sensitivity across different frequencies. - While the Bing test is part of audiological assessment, its primary purpose is not to determine overall hearing ability but rather to assess the occlusion effect. *Evaluating sound conduction through air* - Tests like **air conduction audiometry** directly evaluate the transmission of sound through the outer and middle ear via air. - The Bing test primarily focuses on **bone conduction** using a tuning fork on the mastoid, not air conduction. *A general term for various hearing assessments* - This statement describes a category of tests rather than the specific function of the Bing test. - The Bing test is a **specific diagnostic tuning fork test** with a defined purpose, not a general umbrella term.
Question 9: 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.
Question 10: Rosen's incision is used for which surgical procedure?
- A. Septoplasty
- B. Stapedectomy (Correct Answer)
- C. Tonsillectomy
- D. Tympanoplasty
Explanation: ***Stapedectomy*** - **Rosen's incision** is a **curved incision in the posterior ear canal** specifically used for **stapedectomy** surgery. - This incision provides excellent exposure of the **middle ear** and particularly the **stapes footplate** for otosclerosis surgery. - The incision extends from approximately **6 o'clock to 12 o'clock** position in the posterior canal, allowing the tympanomeatal flap to be elevated. *Tympanoplasty* - **Tympanoplasty** (repair of perforated tympanic membrane) can use various incisions including **permeatal**, **endaural**, or **postauricular** approaches. - While transmeatal approaches are used, they are not specifically termed "Rosen's incision," which is reserved for stapes surgery. *Septoplasty* - **Septoplasty** is a nasal procedure for correcting a deviated septum using incisions like **hemitransfixion** or **Killian's incision**. - This procedure involves the **nasal septum**, not the ear canal. *Tonsillectomy* - **Tonsillectomy** is performed entirely through an **oral approach** for removal of palatine tonsils. - No external or ear canal incisions are involved.
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
Start For Free