Diseases of the Ear Practice Questions

Q: A 4-year-old child presents with difficulty hearing and frequent ear infections. An otoscopic examination reveals fluid in the middle ear without signs of acute infection. What is the most likely diagnosis?

Otitis media with effusion. ***Otitis media with effusion*** - The presence of **fluid in the middle ear** without signs of acute infection (e.g., fever, ear pain, bulging tympanic membrane) is characteristic of otitis media with effusion (OME). - This condition is a common cause of **hearing difficulty** and recurrent ear infections in children due to impaired Eustachian tube function. *Acute otitis media* - This diagnosis requires signs of **acute inflammation** and infection, such as ear pain, fever, and a **bulging, erythematous tympanic membrane**, which are absent in this case. - The fluid in acute otitis media is typically purulent and associated with more acute symptoms. *Otitis externa* - **Otitis externa** involves inflammation or infection of the **external ear canal**, often referred to as "swimmer's ear." - Symptoms typically include **ear pain**, itching, and discharge from the ear canal, and the tympanic membrane is usually normal. *Cholesteatoma* - A **cholesteatoma** is an abnormal, **non-cancerous skin growth** that develops in the middle ear, behind the eardrum. - While it can cause hearing loss and recurrent infections, it is characterized by a **retraction pocket** or **perforation** with **squamous debris**, which is not described here.

Q: A 60-year-old male presents with unilateral conductive hearing loss and a pearly white mass behind the tympanic membrane. What is the most likely diagnosis?

Cholesteatoma. ***Cholesteatoma*** - A **pearly white mass** behind an intact tympanic membrane, along with **unilateral conductive hearing loss**, is characteristic of a cholesteatoma. - Cholesteatomas are **destructive epithelial cysts** that can erode ossicles and bone, leading to progressive hearing loss and potential complications. *Otitis media with effusion* - This typically presents with a **dull, retracted tympanic membrane** and a **serous or mucoid effusion**, not a pearly white mass. - While it causes **conductive hearing loss**, it lacks the specific visual hallmark of a cholesteatoma. *Tympanosclerosis* - Characterized by **white plaques** on the tympanic membrane due to hyalinization and calcification, often after recurrent otitis media. - These plaques are usually **superficial** and do not present as a distinct mass *behind* the eardrum. *Foreign body* - A foreign body behind the tympanic membrane is **rare** and would typically be visible as an object, not a pearly white mass. - The history would likely include a clear event of foreign body insertion, which is not mentioned here.

Q: A 4-year-old child presents with a history of recurrent ear infections, poor school performance, and behavioral problems. Audiometry confirms bilateral conductive hearing loss. What is the most likely diagnosis?

Otitis media with effusion. ***Otitis media with effusion*** - **Recurrent ear infections** and **bilateral conductive hearing loss** in a child are classic signs of otitis media with effusion, often leading to **poor school performance** and **behavioral problems** due to impaired communication. - The effusion in the middle ear dampens sound transmission, causing **conductive hearing loss**. *Otosclerosis* - This condition is characterized by **abnormal bone growth** in the middle ear, leading to **progressive conductive hearing loss**, but it typically affects **adults**, not children. - It usually presents with a gradual onset of hearing loss and **tinnitus**, without a history of recurrent infections. *Congenital hearing loss* - While it causes **bilateral hearing loss**, it is present **from birth** and would likely be identified earlier during newborn screening or developmental milestones. - It is not typically associated with a history of **recurrent ear infections** or poor school performance as a presenting symptom in a 4-year-old in this manner. *Acute otitis media* - This involves an **acute bacterial or viral infection** of the middle ear, causing symptoms like **fever**, **ear pain**, and temporary hearing loss. - While recurrent episodes can lead to OME, **acute otitis media** itself describes a transient, painful infection, not the chronic effusion and associated developmental issues described.

Q: A 3-year-old child presents with severe otalgia, fever of 39.5°C for 2 days, and bulging tympanic membrane. What is the primary treatment for this acute otitis media?

Antibiotics. ***Antibiotics*** - **Antibiotics** are the primary treatment for **severe acute otitis media (AOM)** with high fever (≥39°C), severe otalgia, or bilateral disease in young children. - Common pathogens include *Streptococcus pneumoniae*, *Haemophilus influenzae*, and *Moraxella catarrhalis*. - First-line therapy is **high-dose amoxicillin** (80-90 mg/kg/day); **amoxicillin-clavulanate** if amoxicillin failure or recent antibiotic use. - Prompt treatment in severe cases prevents complications like **mastoiditis**, **meningitis**, and **hearing loss**. *Antiviral medication* - **Antiviral medications** are ineffective against AOM, which is primarily a **bacterial infection**. - While viral URTIs may precede AOM, the middle ear infection itself requires antibacterial therapy in severe cases. *Steroids* - **Steroids** reduce inflammation but do not address the underlying **bacterial infection**. - No role as primary treatment; may be considered as adjunct in specific cases with severe inflammation. *Observation only* - **Watchful waiting** (observation with analgesics) is appropriate for **non-severe AOM** in children >6 months with: - Unilateral AOM without severe symptoms - Mild otalgia and fever <39°C - Reliable follow-up available - However, in **severe AOM** with high fever and severe pain (as in this case), **immediate antibiotics** are indicated per AAP guidelines.

Q: A 35-year-old patient presents with recurrent otitis media. Tympanometry reveals a type B tympanogram. What is the best management option?

Myringotomy with tube placement. ***Myringotomy with tube placement*** - A type B tympanogram indicates greatly reduced or no **tympanic membrane (TM) mobility**, signifying **middle ear effusion** or **perforation**. Recurrent otitis media in this context suggests persistent middle ear fluid, for which **myringotomy with tube placement** is the definitive treatment to drain fluid and ventilate the middle ear. - This procedure prevents further fluid accumulation, reduces the frequency of acute otitis media episodes, and helps improve hearing. *Surgical consultation for ossicular chain* - While ossicular chain problems can cause hearing loss, they typically do not present with **recurrent otitis media** or a **type B tympanogram** indicating fluid. Ossicular issues are more likely to present with a **Type As tympanogram** (stiff ossicles) or a **Type Ad tympanogram** (disarticulation). - Investigating the ossicular chain would be indicated if other causes were ruled out or if conductive hearing loss persists after middle ear fluid resolution. *Topical antibiotics for perforation* - Topical antibiotics are used to treat active **infections in cases of tympanic membrane perforation** but do not address the underlying Eustachian tube dysfunction or persistent middle ear fluid that leads to recurrent otitis media. - A type B tympanogram could indicate a perforation if volume is large, but the primary issue in recurrent OM is typically fluid, not just the perforation itself. *Decongestants for Eustachian dysfunction* - **Decongestants** are sometimes used for **Eustachian tube dysfunction** but have limited efficacy in cases of recurrent otitis media with established middle ear effusion, especially in adults. - Their primary role is to reduce nasal congestion, which can indirectly help Eustachian tube function, but they don't directly resolve persistent fluid.

Q: A patient presented with the following picture of Tympanic Membrane. Most Probable diagnosis (marked with arrow):

Tubercular Otitis Media. ***Tubercular Otitis Media*** - The image exhibits **multiple perforations** in the tympanic membrane, along with **pale granulation tissue**, which are classic clinical features of **tubercular otitis media**. - Tubercular ear infections often present insidiously with **painless otorrhea** and **progressive hearing loss**, eventually leading to multiple perforations as the disease advances. *Syphilitic Otitis Media* - Syphilitic otitis media typically presents as **sensorineural hearing loss**, often sudden, and can be associated with **vestibular symptoms**. - It usually does **not cause multiple perforations** or extensive granulation tissue in the tympanic membrane. *Pseudomonas infection* - **Pseudomonas otitis externa** commonly causes severe pain, swelling, and purulent discharge, often seen in _elderly diabetic_ or _immunocompromised_ patients with potentially **malignant otitis externa**. - While *Pseudomonas* can cause chronic suppurative otitis media (CSOM) with a perforation, it doesn't typically lead to **multiple perforations** in the manner depicted. *Fungal Otitis Media* - Fungal otitis media (otomycosis) is characterized by the presence of **black, white, or yellow fungal debris** and hyphae within the external ear canal and on the tympanic membrane. - While it can cause inflammation and sometimes perforation, the image does not show characteristic **fungal elements** or the extensive **granulation tissue** typical of tubercular disease.

Q: Identify the condition based on the provided image.

Keratosis obturans. ***Keratosis obturans*** - Characterized by accumulation of **keratin** within the ear canal, leading to **impaction** and potential hearing loss. - Often associated with a **foul odor** and can result in **chronic inflammation** of the ear canal. *Acquired cholesteatoma* - Typically presents as **retraction of the tympanic membrane** and is associated with **recurrent ear infections**. - Unlike keratosis obturans, it involves **destructive growth** of skin cells and can erode neighboring structures, such as the ossicles. *Congenital cholesteatoma* - This condition is present from birth and generally manifests as a **painless mass** in the ear, often behind the tympanic membrane. - Unlike keratosis obturans, there is minimal **inflammation** and it is not related to **keratin accumulation** in the canal. *Rupture of tympanic membrane* - Presents with **acute ear pain**, **hearing loss**, and may show fluid or blood in the ear canal but not **keratin debris**. - The presence of **perforation** is central to this diagnosis and is not indicative of the keratin buildup seen in keratosis obturans.

Q: All of the following are true about malignant otitis externa except which of the following?

Severe hearing loss is the chief presenting complaint. ***Severe hearing loss is the chief presenting complaint*** - While otitis externa can cause mild to moderate conductive **hearing loss** due to swelling and debris, severe hearing loss is **not** typically the chief presenting complaint of **malignant otitis externa**. Instead, patients usually present with severe **otalgia** (ear pain), **otorrhea** (ear discharge), and granulation tissue in the external auditory canal. - The hallmark presentation is **severe, unrelenting otalgia** that is out of proportion to clinical findings, often worse at night. Hearing loss is a secondary feature, not the primary complaint. *ESR is used for follow up after treatment* - **Erythrocyte Sedimentation Rate (ESR)** is a valuable marker for assessing inflammatory activity in **malignant otitis externa** and is commonly utilized to monitor treatment response. - A decrease in ESR indicates successful treatment and resolution of the infection, making it a reliable tool for follow-up. *Granulation tissues are seen on the floor of the external auditory canal* - The presence of **granulation tissue** at the bony-cartilaginous junction of the external auditory canal, particularly on the **floor (inferior wall)**, is a hallmark diagnostic sign of **malignant otitis externa**. - This finding at the floor of the EAC is a classic and highly specific sign indicating osteomyelitis of the temporal bone. *Pseudomonas is the most common cause* - **Pseudomonas aeruginosa** is indeed the predominant pathogen responsible for approximately **90-95%** of **malignant otitis externa** cases. - This gram-negative bacterium is particularly opportunistic in immunocompromised individuals, especially elderly diabetics.

Q: Which of the following statements about serous otitis media is false?

Type C tympanogram. ***Type C tympanogram*** (FALSE statement) - A **Type C tympanogram** indicates **negative middle ear pressure**, which suggests **eustachian tube dysfunction** or early/resolution phase, but is **NOT the characteristic finding** in active serous otitis media with persistent fluid. - In serous otitis media with established fluid, a **Type B tympanogram** (flat) is the typical finding, indicating limited or no tympanic membrane mobility due to fluid behind the drum. - Type C may be seen in early eustachian tube dysfunction before fluid accumulates, or during resolution, but not in established glue ear. *Also called glue ear* (TRUE statement) - Serous otitis media is indeed commonly referred to as **"glue ear"** due to the thick, viscous fluid that accumulates in the middle ear space. - This term highlights the characteristic consistency of the effusion, which can significantly impair hearing. *Affect school going children* (TRUE statement) - **School-going children** are highly susceptible to serous otitis media, with peak prevalence between **2 and 6 years of age**. - Contributing factors include developing **eustachian tube anatomy**, frequent upper respiratory infections, and adenoid hypertrophy. *Fluid in middle ear* (TRUE statement) - The defining characteristic of serous otitis media is the presence of **non-purulent fluid** in the middle ear space. - This fluid accumulates due to **eustachian tube dysfunction**, leading to negative pressure and transudation of fluid.

Question 1

A 4-year-old child presents with difficulty hearing and frequent ear infections. An otoscopic examination reveals fluid in the middle ear without signs of acute infection. What is the most likely diagnosis?

Accepted Answer

Otitis media with effusion

Answer

Acute otitis media

Answer

Otitis externa

Answer

Cholesteatoma

Question 2

A 60-year-old male presents with unilateral conductive hearing loss and a pearly white mass behind the tympanic membrane. What is the most likely diagnosis?

Accepted Answer

Cholesteatoma

Answer

Otitis media with effusion

Answer

Tympanosclerosis

Answer

Foreign body

Question 3

A 4-year-old child presents with a history of recurrent ear infections, poor school performance, and behavioral problems. Audiometry confirms bilateral conductive hearing loss. What is the most likely diagnosis?

Accepted Answer

Otitis media with effusion

Answer

Otosclerosis

Answer

Congenital hearing loss

Answer

Acute otitis media

Question 4

A 3-year-old child presents with severe otalgia, fever of 39.5°C for 2 days, and bulging tympanic membrane. What is the primary treatment for this acute otitis media?

Accepted Answer

Antibiotics

Answer

Antiviral medication

Answer

Steroids

Answer

Observation only

Question 5

A 35-year-old patient presents with recurrent otitis media. Tympanometry reveals a type B tympanogram. What is the best management option?

Accepted Answer

Myringotomy with tube placement

Answer

Surgical consultation for ossicular chain

Answer

Topical antibiotics for perforation

Answer

Decongestants for Eustachian dysfunction

Question 6

A patient presented with the following picture of Tympanic Membrane. Most Probable diagnosis (marked with arrow):

Accepted Answer

Tubercular Otitis Media

Answer

Syphilitic Otitis Media

Answer

Pseudomonas infection

Answer

Fungal Otitis Media

Question 7

Identify the condition based on the provided image.

Accepted Answer

Keratosis obturans

Answer

Acquired cholesteatoma

Answer

Congenital cholesteatoma

Answer

Rupture of tympanic membrane

Question 8

All of the following are true about malignant otitis externa except which of the following?

Accepted Answer

Severe hearing loss is the chief presenting complaint

Answer

Pseudomonas is the most common cause

Answer

ESR is used for follow up after treatment

Answer

Granulation tissues are seen on the floor of the external auditory canal

Question 9

Which of the following statements about serous otitis media is false?

Accepted Answer

Type C tympanogram

Answer

Affect school going children

Answer

Also called glue ear

Answer

Fluid in middle ear

Question 10

A 10 year old child presents with painless, non-foul-smelling purulent discharge from the ear. Patient reports that he is able to hear better in the presence of discharge than when the ear is dry. The most probable diagnosis is

Accepted Answer

Chronic suppurative otitis media (CSOM) with tympanic membrane perforation

Answer

Otitis media with effusion

Answer

Mastoiditis with pain and swelling

Answer

Cholesteatoma with foul-smelling discharge

Diseases of the Ear — MCQs

Diseases of the Ear — MCQs

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