Diseases of the Ear Practice Questions

Q: Referred otalgia can be due to which of the following?

All of the above. **Explanation:** Referred otalgia occurs when pain is perceived in the ear due to a disease process in a remote area that shares the same sensory nerve supply. The ear has a complex nerve supply involving the **Trigeminal (V3), Facial (VII), Glossopharyngeal (IX), Vagus (X), and Cervical nerves (C2, C3).** * **Carcinoma of the Larynx (Option A):** The larynx is supplied by the **Vagus nerve** (Superior and Recurrent laryngeal nerves). Pain is referred to the ear via the **Arnold’s nerve** (Auricular branch of the Vagus), which supplies the external auditory canal. * **Carcinoma of the Oral Cavity (Option B):** The anterior two-thirds of the tongue and the floor of the mouth are supplied by the **Lingual nerve (V3)**. Pain is referred via the **Auriculotemporal nerve** (another branch of V3), which supplies the skin of the pinna and temple. * **Carcinoma of the Tongue (Option C):** The posterior one-third of the tongue and the base of the tongue are supplied by the **Glossopharyngeal nerve**. Pain is referred via the **Jacobson’s nerve** (Tympanic branch of IX), which supplies the middle ear mucosa. Since all three regions share nerve pathways with the ear, they all cause referred otalgia. Therefore, **Option D** is correct. **High-Yield Clinical Pearls for NEET-PG:** 1. **Jacobson’s Nerve (IX):** Most common cause of referred otalgia following **Tonsillectomy**. 2. **Arnold’s Nerve (X):** Responsible for the **Ear-Cough Reflex** (coughing during ear syringing). 3. **Rule of Thumb:** In an elderly patient with a normal ear examination complaining of earache, always perform a thorough endoscopic examination of the upper aerodigestive tract to rule out malignancy.

Q: A 5-year-old child has had eight episodes of acute otitis media in 6 months and has difficulty resolving the effusions between infections. What is the most effective management strategy?

Adenoidectomy. **Explanation:** The core issue in this clinical scenario is **Recurrent Acute Otitis Media (RAOM)** with persistent **Otitis Media with Effusion (OME)**. The frequency of infections (8 episodes in 6 months) and the failure to resolve effusions suggest a chronic underlying mechanical or infectious focus. **Why Adenoidectomy is the Correct Answer:** The adenoids play a dual role in the pathogenesis of recurrent ear infections. First, **adenoid hypertrophy** can mechanically obstruct the Eustachian tube orifice, leading to negative middle ear pressure and effusion. Second, and more importantly, the adenoids act as a **bacterial reservoir (biofilm)** for otopathogens like *S. pneumoniae* and *H. influenzae*. Removing the adenoids eliminates this source of infection and improves Eustachian tube function, making it the most effective long-term management strategy for refractory cases. **Analysis of Incorrect Options:** * **Option A:** Treating each infection reactively fails to address the anatomical/pathological predisposition, leading to further recurrence and potential hearing loss. * **Option B:** While ventilating tubes (myringotomy) help drain fluid and equalize pressure, they do not address the source of infection (the adenoids). In children over 4 years with recurrent issues, adenoidectomy is often preferred or combined with tubes. * **Option C:** Prophylactic antibiotics are no longer recommended as a primary strategy due to the high risk of antibiotic resistance and limited long-term efficacy compared to surgical intervention. **Clinical Pearls for NEET-PG:** * **Definition of RAOM:** $\ge$ 3 episodes in 6 months or $\ge$ 4 episodes in 12 months. * **Indications for Adenoidectomy:** Recurrent OM (especially if >4 years old), chronic sinusitis, and obstructive sleep apnea (OSA). * **Most common organism in AOM:** *Streptococcus pneumoniae*. * **First-line Antibiotic:** High-dose Amoxicillin.

Q: Mastoid infection which erodes through the outer cortex of bone results in what?

Sub-periosteal abscess. ### Explanation **1. Why Sub-periosteal Abscess is Correct:** The mastoid bone is bounded laterally by the **outer cortex** and medially by the inner table (which separates it from the brain). In acute coalescent mastoiditis, pus accumulates under pressure within the mastoid air cells. When this infection erodes through the **outer cortex**, the pus collects between the bone and the overlying periosteum, forming a **sub-periosteal abscess**. The most common site for this is the "Post-auricular abscess," which displaces the pinna forwards, downwards, and outwards. **2. Why the Other Options are Incorrect:** * **B. Epidural Abscess:** This occurs when the infection erodes through the **inner table** (posterior or middle cranial fossa plate) rather than the outer cortex. It is an intracranial complication where pus collects between the bone and the dura mater. * **C. Perichondritis:** This is an infection of the cartilage of the pinna, usually following trauma or infected hematoma. It does not originate from the mastoid bone cortex. * **D. Lateral Sinus Thrombosis:** This is a vascular complication caused by the erosion of the **posterior fossa plate** (inner table), leading to inflammation and thrombus formation within the sigmoid/lateral sinus. **3. NEET-PG High-Yield Pearls:** * **Bezold’s Abscess:** Pus erodes through the mastoid tip into the **sternocleidomastoid** sheath (presents as a neck swelling). * **Luc’s Abscess:** Pus erodes through the **meatal wall** into the external auditory canal. * **Citelli’s Abscess:** Pus erodes through the mastoid tip into the **digastric fossa**. * **Zygomatic Abscess:** Pus erodes into the root of the zygoma, causing swelling over the cheek. * **Radiology:** The "Clouding of mastoid air cells" with loss of bony trabeculae (coalescence) is the hallmark of surgical mastoiditis on CT.

Q: A patient with facial nerve paralysis suffers from inability to dampen loud noises due to denervation of which muscle?

Stapedius. **Explanation:** The correct answer is **Stapedius**. This muscle is responsible for the **acoustic reflex** (stapedial reflex), which protects the inner ear from acoustic trauma. **1. Why Stapedius is correct:** The stapedius muscle is the smallest skeletal muscle in the body, located in the middle ear. It is innervated by the **nerve to stapedius**, a branch of the **Facial Nerve (CN VII)**. When exposed to loud sounds (>70-90 dB), the stapedius contracts, pulling the stapes bone away from the oval window. This increases the stiffness of the ossicular chain, dampening the vibrations transmitted to the cochlea. In facial nerve paralysis (e.g., Bell’s palsy), denervation of this muscle leads to **hyperacusis**—a condition where normal sounds appear abnormally loud and painful. **2. Why other options are incorrect:** * **Posterior belly of digastric & Stylohyoid:** While both are supplied by the facial nerve, they are muscles of the neck involved in swallowing and stabilizing the hyoid bone; they have no role in hearing. * **Tensor tympani:** This muscle also dampens sound by tensing the tympanic membrane, but it is innervated by the **Mandibular nerve (V3)**, a branch of the Trigeminal nerve. It would not be affected by a primary facial nerve lesion. **Clinical Pearls for NEET-PG:** * **Hyperacusis** indicates a facial nerve lesion **proximal** to the nerve to stapedius (in the vertical segment of the bony fallopian canal). * The **Stapedial Reflex** is an objective test used in topodiagnostic studies to locate the site of a facial nerve lesion. * The stapedius muscle is derived from the **2nd branchial arch**, whereas the tensor tympani is derived from the **1st branchial arch**.

Q: Which of the following is NOT true about hearing loss in otosclerosis?

Common in males older than 40 years. **Explanation:** Otosclerosis is a primary metabolic bone disease of the otic capsule characterized by the replacement of normal bone with vascular spongy bone, leading to stapedial fixation and conductive hearing loss. **Why Option A is the correct answer (False Statement):** Otosclerosis typically presents in **young adults (20–30 years)** and is significantly more common in **females** (Ratio 2:1). The condition is often exacerbated by hormonal changes such as pregnancy or puberty. Therefore, the statement that it is common in males older than 40 is epidemiologically incorrect. **Analysis of other options:** * **Option B (Associated with vertigo):** While primarily a hearing disorder, "Cochlear Otosclerosis" or "Otospongiosis" can involve the vestibular system, leading to balance disturbances or vertigo in a subset of patients. * **Option C (Paracusis Willisii):** This is a classic clinical feature where the patient hears better in noisy environments. This occurs because background noise causes others to speak louder, and the patient’s conductive loss filters out the low-frequency ambient noise. * **Option D (Schwartz sign):** Also known as the "Flamingo Flush," this is a reddish hue seen through the tympanic membrane due to increased vascularity of the promontory during the active phase of the disease (Otospongiosis). **NEET-PG High-Yield Pearls:** * **Carhart’s Notch:** A characteristic dip in the bone conduction audiogram at **2000 Hz**. * **Gelle’s Test:** Negative (indicates stapes fixation). * **Tympanometry:** Typically shows an **As type** curve (reduced compliance). * **Treatment of Choice:** Stapedotomy (most common) or Stapedectomy. * **Medical Management:** Sodium Fluoride (used to mature active foci).

Q: External auditory canal atresia has been associated with all of the following except?

Polyhydramnios. **Explanation:** Congenital External Auditory Canal (EAC) Atresia occurs due to a failure in the canalization of the first branchial cleft during the 7th month of intrauterine life. It is frequently associated with microtia and ossicular malformations. **Why Polyhydramnios is the Correct Answer:** Polyhydramnios (excessive amniotic fluid) is **not** a known risk factor for EAC atresia. In fact, EAC atresia and associated renal anomalies (as seen in syndromes like Townes-Brocks) are more frequently linked with **Oligohydramnios** (deficient amniotic fluid) due to decreased fetal urine production. Polyhydramnios is typically associated with fetal gastrointestinal obstructions or CNS anomalies that interfere with swallowing. **Analysis of Incorrect Options:** * **Low Birth Weight:** Prematurity and low birth weight are statistically significant risk factors for various congenital craniofacial anomalies, including aural atresia. * **Intrauterine Infections:** TORCH infections (especially **Rubella**) are well-documented causes of congenital ear malformations and sensorineural hearing loss. * **Intrauterine Toxins:** Teratogenic exposure during the first trimester is a major cause. Classic examples include **Thalidomide**, Isotretinoin (Vitamin A derivatives), and maternal alcohol consumption. **High-Yield Clinical Pearls for NEET-PG:** * **Embryology:** The EAC develops from the **1st Branchial Cleft**; the Pinna develops from **6 Hillocks of His** (1st and 2nd arches). * **Syndromic Associations:** EAC atresia is commonly seen in **Treacher Collins Syndrome**, **Goldenhar Syndrome**, and **Branchio-Oto-Renal (BOR) Syndrome**. * **Management:** The gold standard for evaluation is a **High-Resolution CT (HRCT) of the Temporal Bone** to assess the Jahrsdoerfer scale score before surgical reconstruction.

Q: The pressure difference that can cause atmosphere and middle ear barotrauma is:

> 90 mmHg. **Explanation:** **1. The Correct Answer: D (> 90 mmHg)** Barotrauma occurs due to a failure of the Eustachian tube (ET) to equalize pressure between the middle ear and the external environment, most commonly during rapid descent in flights or diving. * When the negative pressure in the middle ear reaches **90 mmHg** relative to the atmosphere, it creates a "locking" effect. * At this critical pressure gradient, the tensor veli palatini muscle is unable to overcome the vacuum to open the ET. This is known as **Eustachian Tube Locking**. If the pressure difference exceeds this limit, the tympanic membrane may retract severely, leading to mucosal edema, transudate (serous otitis), or hemorrhage. **2. Why Other Options are Incorrect:** * **A, B, and C (60–80 mmHg):** While these pressure differences cause significant discomfort, ear fullness, and pain (otalgia), they are generally below the threshold of the "locking" phenomenon. At these levels, the patient can still potentially equalize pressure using the **Valsalva maneuver**. The physiological "point of no return" where the tube is physically held shut by suction is specifically cited in medical literature as > 90 mmHg. **3. Clinical Pearls for NEET-PG:** * **Most common cause:** Descent in an aircraft (negative middle ear pressure). * **Eustachian Tube Locking:** Occurs at > 90 mmHg; at this stage, Valsalva will fail and may actually worsen the condition. * **Teed’s Classification:** Used to grade the severity of middle ear barotrauma (Grade 0 to 5). * **Prevention:** Chewing gum, swallowing, or performing the Toynbee/Valsalva maneuver during descent. * **Treatment:** Decongestants (nasal and oral) to reduce ET edema; myringotomy is reserved for severe cases with persistent fluid or hemotympanum.

Q: Lateral sinus thrombosis is associated with all of the following except:

Gradenigo triad. **Explanation:** **Lateral Sinus Thrombosis (LST)**, also known as Sigmoid Sinus Thrombosis, is a serious intracranial complication of chronic suppurative otitis media (CSOM). It occurs when infection spreads to the venous sinus, leading to thrombus formation. **Why Gradenigo Triad is the Correct Answer:** Gradenigo triad is the hallmark of **Petrositis** (infection of the petrous apex), not lateral sinus thrombosis. It consists of: 1. **Abducens (VI) nerve palsy** (causing diplopia). 2. **Deep-seated retro-orbital pain** (due to Trigeminal/V nerve involvement). 3. **Persistent ear discharge.** **Analysis of Other Options (Associated with LST):** * **Griesinger’s Sign:** Edema and tenderness over the mastoid process due to thrombosis of the **mastoid emissary vein**. * **Crowe-Beck Sign:** Engorgement of retinal veins and supraorbital veins upon manual compression of the internal jugular vein (IJV) on the healthy side. * **Tobey-Ayer Test:** A manometric test during lumbar puncture. Compression of the IJV on the diseased side causes no rise in CSF pressure, whereas compression on the healthy side causes a rapid rise. **High-Yield Clinical Pearls for NEET-PG:** * **Picket-fence fever:** The characteristic clinical presentation of LST (hectic spikes with chills and rigors). * **Greisinger's sign** is a classic physical exam finding for LST. * **Investigation of Choice:** MR Venogram (shows the "Empty Delta Sign"). * **Management:** Intravenous antibiotics, anticoagulants, and mastoidectomy with clot removal if necessary.

Q: What is the most common cause of bilateral conductive deafness in a child?

Otitis media with effusion (OME). **Explanation:** **1. Why Otitis Media with Effusion (OME) is correct:** Otitis media with effusion (also known as "Glue Ear") is the most common cause of hearing impairment in children worldwide. It is characterized by the presence of non-purulent fluid in the middle ear space without signs of acute infection. In children, the Eustachian tube is shorter, wider, and more horizontal, making it prone to dysfunction (often due to adenoid hypertrophy). This leads to negative middle ear pressure and fluid accumulation, resulting in a **bilateral conductive hearing loss (CHL)** typically ranging from 20–40 dB. **2. Why other options are incorrect:** * **Otosclerosis:** This is a common cause of CHL in **adults** (usually 20–40 years), characterized by stapes fixation. It is rare in the pediatric population. * **Acute Otitis Media (AOM):** While AOM causes CHL, it is an acute inflammatory condition presenting with pain and fever. OME is the more common cause of *persistent* bilateral deafness. * **Congenital Cholesteatoma:** This is usually a **unilateral** condition presenting as a white mass behind an intact tympanic membrane. It is far less common than OME. **3. High-Yield Clinical Pearls for NEET-PG:** * **Investigation of Choice:** Impedance Audiometry (Tympanometry). * **Classic Finding:** **Type B (Flat) Tympanogram** with normal ear canal volume. * **Otoscopy:** Dull, retracted tympanic membrane with loss of light reflex; "air-bubbles" or an air-fluid level may be visible. * **Treatment of Choice:** Initially medical (observation/nasal decongestants); if persistent (>3 months) or causing speech delay, **Myringotomy with Grommet insertion** is indicated. * **Most common site for Grommet:** Antero-inferior quadrant of the tympanic membrane.

Question 1

Referred otalgia can be due to which of the following?

Accepted Answer

All of the above

Answer

Carcinoma of the larynx

Answer

Carcinoma of the oral cavity

Answer

Carcinoma of the tongue

Question 2

A 5-year-old child has had eight episodes of acute otitis media in 6 months and has difficulty resolving the effusions between infections. What is the most effective management strategy?

Accepted Answer

Adenoidectomy

Answer

Treating each infection as it arises

Answer

Placement of ventilating tubes

Answer

Prescribing prophylactic antibiotics for 6 months

Question 3

Mastoid infection which erodes through the outer cortex of bone results in what?

Accepted Answer

Sub-periosteal abscess

Answer

Epidural abscess

Answer

Perichondritis

Answer

Lateral sinus thrombosis

Question 4

A patient with facial nerve paralysis suffers from inability to dampen loud noises due to denervation of which muscle?

Accepted Answer

Stapedius

Answer

Posterior belly of digastric

Answer

Tensor tympani

Answer

Stylohyoid Muscle

Question 5

Which of the following is NOT true about hearing loss in otosclerosis?

Accepted Answer

Common in males older than 40 years

Answer

Associated with vertigo

Answer

Characterized by Paracusis Willisii

Answer

May present with Schwartz sign

Question 6

What is the treatment of choice in central perforation?

Accepted Answer

Tympanoplasty

Answer

Modified mastoidectomy

Answer

Myringoplasty

Answer

Conservative management

Question 7

External auditory canal atresia has been associated with all of the following except?

Accepted Answer

Polyhydramnios

Answer

Low birth weight

Answer

Intrauterine infections

Answer

Intrauterine toxins

Question 8

The pressure difference that can cause atmosphere and middle ear barotrauma is:

Accepted Answer

> 90 mmHg

Answer

60 mmHg

Answer

60 - 70 mmHg

Answer

70-80 mmHg

Question 9

Lateral sinus thrombosis is associated with all of the following except:

Accepted Answer

Gradenigo triad

Answer

Griesinger's sign

Answer

Crowe-Beck sign

Answer

Tobey-Ayer test

Question 10

What is the most common cause of bilateral conductive deafness in a child?

Accepted Answer

Otitis media with effusion (OME)

Answer

Otosclerosis

Answer

Acute otitis media

Answer

Congenital cholesteatoma

Diseases of the Ear — MCQs

Diseases of the Ear — MCQs

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