Diseases of the Ear Practice Questions

Q: Which of the following statements are true about otitis media with effusion in a child?

A Type B tympanogram is observed.. **Explanation:** **Otitis Media with Effusion (OME)**, also known as "Glue Ear," is characterized by the accumulation of non-purulent fluid in the middle ear cleft without signs of acute infection. 1. **Why Option B is Correct:** Tympanometry is the gold standard for diagnosing OME. A **Type B (Flat) tympanogram** is observed because the fluid behind the tympanic membrane increases its mass and stiffness, resulting in restricted mobility. This leads to a lack of a compliance peak, regardless of the pressure changes applied. 2. **Why the Other Options are Incorrect:** * **Option A:** Immediate myringotomy is not indicated. The initial management is **watchful waiting** for 3 months, as many cases resolve spontaneously. Surgery (myringotomy with grommet insertion) is reserved for persistent or bilateral cases with significant hearing loss. * **Option C:** While the fluid is non-purulent, it is **not always sterile**. Studies have shown that bacteria (like *H. influenzae* or *S. pneumoniae*) or biofilms are present in approximately 30-50% of cases, though they do not cause acute symptoms. * **Option D:** OME is the most common cause of **conductive** hearing loss in children, but it is not the most common cause of "deafness" (a term usually implying profound sensorineural loss) in daycare settings. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause:** Eustachian tube dysfunction (often due to adenoid hypertrophy in children). * **Otoscopy findings:** Dull/opaque tympanic membrane, retracted drum, or presence of air bubbles/fluid levels. * **Hearing loss:** Conductive type, usually 20–40 dB. * **Treatment of choice (Surgical):** Myringotomy with **Grommet (Ventilation tube)** insertion, typically in the antero-inferior quadrant. * **Rule of thumb:** In an adult with unilateral OME, always rule out **Nasopharyngeal Carcinoma**.

Q: What is the appropriate treatment for an acute stable hematoma of the pinna of the ear?

Incision, drainage, and pressure bandage. **Explanation:** The primary goal in managing an auricular hematoma is to evacuate the blood collection and prevent its recurrence. The pinna's cartilage relies on the overlying perichondrium for its blood supply. A hematoma creates a space between these layers, leading to ischemic necrosis of the cartilage if not treated promptly. **Why Option D is Correct:** **Incision and Drainage (I&D)** followed by a **pressure bandage** is the gold standard. I&D ensures complete evacuation of the clot (which may be too viscous for a needle). The pressure bandage is crucial because it obliterates the "dead space," preventing the re-accumulation of blood and ensuring the perichondrium re-adheres to the cartilage. **Why Other Options are Incorrect:** * **Option A:** Ice packs may reduce swelling but will not remove the existing extravasated blood. Antibiotics are supportive but do not address the mechanical problem. * **Option B:** Excision implies removing tissue; only the blood collection needs removal, not the ear tissue itself. * **Option C:** Needle aspiration is associated with a high rate of recurrence (up to 70%) because the small bore cannot evacuate organized clots and the space often refills immediately without a formal pressure dressing. **High-Yield Clinical Pearls for NEET-PG:** * **Cauliflower Ear:** The classic complication of untreated or inadequately treated hematoma, where fibrocartilage overgrowth leads to permanent deformity. * **Timeframe:** Treatment should ideally occur within **48–72 hours** of injury. * **Incision Site:** Usually made along the natural curvature of the helical rim to minimize scarring. * **Antibiotics:** Post-procedure antibiotics should cover *Pseudomonas aeruginosa* (e.g., Fluoroquinolones), as it is the most common cause of secondary perichondritis.

Q: Hyperacusis is seen in all of the following conditions except:

Otosclerosis. **Explanation:** **Hyperacusis** is a condition characterized by an increased sensitivity or intolerance to ordinary environmental sounds. It typically occurs due to the loss of the protective **stapedial reflex** (mediated by the facial nerve) or recruitment phenomena in cochlear disorders. **Why Otosclerosis is the Correct Answer:** In **Otosclerosis**, there is fixation of the stapes footplate in the oval window. This leads to **Conductive Hearing Loss (CHL)**. Patients with CHL actually experience the opposite of hyperacusis; they often perceive their own voice as louder (autophony) and find noisy environments helpful for hearing (Paracusis Willisii). Since the stapes is fixed, the ear is "protected" from sound transmission, making hyperacusis clinically inconsistent with this diagnosis. **Analysis of Incorrect Options:** * **Exposure to loud sounds:** Acute acoustic trauma can damage the hair cells and disrupt the auditory processing pathway, leading to temporary or permanent hyperacusis. * **Meniere’s disease:** This is a classic cause of **Recruitment**. In recruitment, the ear abnormally perceives a small increase in physical sound intensity as a large increase in loudness, leading to intolerance of loud sounds despite having hearing loss. * **Severe head injury:** Trauma can result in a perilymph fistula, facial nerve paralysis (loss of stapedial reflex), or central auditory pathway damage, all of which are known triggers for hyperacusis. **NEET-PG High-Yield Pearls:** * **Facial Nerve Palsy:** Hyperacusis occurs if the nerve to the stapedius (a branch of CN VII) is involved, as the stapedius muscle can no longer dampen loud sounds. * **Recruitment vs. Hyperacusis:** Recruitment is specific to cochlear lesions (e.g., Meniere’s), whereas hyperacusis is a broader term for sound intolerance. * **Bell’s Palsy:** Hyperacusis is a key prognostic clinical sign indicating a lesion proximal to the middle ear.

Q: What is the characteristic of glue ear?

Painless. **Explanation:** **Glue Ear**, clinically known as **Otitis Media with Effusion (OME)**, is characterized by the accumulation of non-purulent, mucoid fluid in the middle ear cleft. 1. **Why "Painless" is correct:** Unlike acute otitis media, there is no active infection or suppuration causing pressure on the tympanic membrane. The primary pathology is **Eustachian tube dysfunction**, leading to negative middle ear pressure and fluid transudation. The hallmark symptom is **painless hearing loss** (conductive) and a feeling of ear fullness, especially in children. 2. **Analysis of Incorrect Options:** * **Painful:** Pain (otalgia) is a feature of Acute Otitis Media (AOM) or Otitis Externa. OME is typically silent and often discovered during routine school screenings. * **Naf (Sodium Fluoride) is useful:** This is incorrect. Sodium Fluoride is used in the treatment of **Otosclerosis** (active phase/Otospongiosis) to inhibit osteoclastic activity. It has no role in managing middle ear fluid. * **Radical mastoidectomy is required:** This is an aggressive surgery for cholesteatoma or chronic suppurative otitis media (CSOM). Glue ear is managed conservatively (watchful waiting, autoinflation) or via **Myringotomy with Grommet insertion**. **High-Yield Clinical Pearls for NEET-PG:** * **Otoscopy Finding:** The tympanic membrane appears dull, opaque, and retracted. You may see **air bubbles** or an amber-colored fluid level. * **Tympanometry:** Shows a **Type B (flat) curve**, indicating fluid behind the drum. * **Treatment of Choice:** Myringotomy with Grommet insertion (usually in the antero-inferior quadrant). * **Association:** In adults, unilateral glue ear is a "red flag" and necessitates an examination of the nasopharynx to rule out **Nasopharyngeal Carcinoma**.

Q: What is the angle made by the tympanic membrane with the floor of the external auditory meatus?

55 degrees. The tympanic membrane (TM) is not positioned vertically within the ear canal; instead, it is set obliquely. In an adult, the TM forms an **angle of approximately 55 degrees** with the floor of the external auditory meatus [2]. This orientation is crucial because it increases the surface area of the membrane available for sound collection compared to a strictly vertical arrangement. * **Why 55 degrees is correct:** Anatomically, the anterior and inferior walls of the external auditory canal are longer than the posterior and superior walls. This discrepancy causes the TM to tilt, making an acute angle of 55° with the floor [2]. In neonates, this angle is even more acute, making the drum appear almost horizontal. * **Why other options are incorrect:** * **35 degrees:** This is too acute for a normal adult ear; such an angle is more characteristic of the horizontal positioning seen in newborns. * **75 degrees:** This would represent a more vertical drum than what is anatomically present. * **90 degrees:** A perpendicular orientation does not exist in human anatomy; it would significantly reduce the functional surface area of the TM. **Clinical Pearls for NEET-PG:** 1. **Cone of Light:** Due to this oblique tilt and the concavity of the drum (at the umbo), light is reflected antero-inferiorly. 2. **Anterior Recess:** The acute angle formed between the TM and the anterior canal wall creates a "recess" where debris or small foreign bodies can often become trapped [2]. 3. **Pars Tensa vs. Flaccida:** The majority of the TM is the Pars Tensa (thick), while the superior portion is the Pars Flaccida (Shrapnell’s membrane), which lacks the organized fibrous middle layer [1].

Q: What is the commonest causative organism for acute suppurative otitis media (ASOM) in a 2-year-old child?

Streptococcus pneumoniae. **Explanation:** **Streptococcus pneumoniae** is the most common causative organism for Acute Suppurative Otitis Media (ASOM) across all age groups, including children. In a 2-year-old, the Eustachian tube is shorter, wider, and more horizontal, facilitating the migration of nasopharyngeal flora into the middle ear. *S. pneumoniae* accounts for approximately 30–50% of bacterial isolates in these cases. **Analysis of Options:** * **A. Streptococcus pneumoniae (Correct):** It remains the leading pathogen globally. While the introduction of the Pneumococcal Conjugate Vaccine (PCV) has shifted the prevalence of specific serotypes, it has not displaced *S. pneumoniae* as the primary cause. * **B. Streptococcus pyogenes:** Formerly a common cause of severe ASOM with early perforation, its incidence has significantly declined in the antibiotic era. * **C. Staphylococcus aureus:** While a common cause of chronic otitis media or otitis externa, it is an infrequent primary pathogen in acute middle ear infections. * **D. Haemophilus influenzae:** This is the **second** most common cause (non-typeable *H. influenzae*). It is frequently associated with "Otitis-Conjunctivitis Syndrome" and is more likely to be found in bilateral cases or those failing initial therapy. **High-Yield Clinical Pearls for NEET-PG:** 1. **Order of Frequency:** *S. pneumoniae* > *H. influenzae* > *Moraxella catarrhalis*. 2. **Viral Etiology:** Most ASOM cases are preceded by a viral URI (RSV, Rhinovirus). 3. **Drug of Choice:** Amoxicillin remains the first-line treatment. 4. **Complication:** The most common extracranial complication of ASOM is Acute Mastoiditis.

Q: A boy with acute suppurative otitis media (ASOM) is undergoing treatment with penicillin therapy for 7 days. He now presents with subsidence of pain and persistence of deafness. What is the most likely diagnosis?

Secretory otitis media. **Explanation:** The scenario describes a classic case of **"Masked Mastoiditis"** or **Resolution of ASOM into Secretory Otitis Media (SOM)** due to inadequate or incomplete antibiotic therapy. **Why Secretory Otitis Media is correct:** In ASOM, penicillin effectively treats the acute bacterial infection, leading to the subsidence of pain (otalgia) and fever. However, if the underlying Eustachian tube dysfunction persists or if the infection is only partially resolved, sterile fluid remains trapped in the middle ear cleft. This transition from an acute suppurative stage to a chronic non-suppurative stage results in persistent **conductive hearing loss** (deafness) despite the disappearance of acute symptoms. **Why the other options are incorrect:** * **Ototoxicity:** Penicillin is not ototoxic. Ototoxicity (usually caused by aminoglycosides) typically presents with sensorineural hearing loss and vertigo, not as a sequel to treated ASOM. * **Adhesive Otitis Media:** This is a late-stage complication where the tympanic membrane becomes retracted and "plastered" onto the promontory due to long-standing negative pressure. It does not occur acutely within 7 days. * **Tympanosclerosis:** This refers to hyalinization and calcification of the tympanic membrane (chalky white patches). It is a sequela of chronic inflammation, not an immediate post-treatment finding of ASOM. **NEET-PG High-Yield Pearls:** * **Masked Mastoiditis:** Often caused by inadequate antibiotic dose/duration. The classic triad is: *subsidence of pain, persistent deafness, and a thickened/dull tympanic membrane.* * **Treatment of choice for SOM:** Initially medical (decongestants); if persistent, **Myringotomy with Grommet insertion**. * **Hearing Loss Type:** ASOM and SOM both cause **Conductive Hearing Loss**. If a patient develops vertigo or SNHL, suspect labyrinthitis.

Q: A 3-year-old girl ruptured her eardrum when she inserted a pencil into her ear. Her mother took her to the emergency department after noticing that the child was crying and complaining of pain in her ear with a few drops of blood in the external auditory meatus. The attending doctor examined the child for possible injury to a nerve that runs across the eardrum. Which is the MOST likely nerve to be injured?

Chorda tympani. **Explanation:** **1. Why Chorda Tympani is Correct:** The **chorda tympani** is a branch of the facial nerve (CN VII) that carries taste sensation from the anterior two-thirds of the tongue and parasympathetic fibers to the submandibular and sublingual glands. Anatomically, it enters the middle ear through the posterior canaliculus and runs across the medial surface of the **upper part of the tympanic membrane (pars tensa)**, passing between the handle of the malleus and the long process of the incus. Due to its superficial position directly medial to the eardrum, it is the nerve most vulnerable to injury during traumatic tympanic membrane perforations (like pencil injuries) or middle ear surgeries (like stapedectomy). **2. Why Other Options are Incorrect:** * **Auricular branch of the vagus (Arnold’s nerve):** This nerve supplies the skin of the external auditory canal and the lateral surface of the tympanic membrane. While it mediates the "ear-cough reflex," it does not run *across* the drum; it is sensory to the outer surface. * **Glossopharyngeal nerve (CN IX):** It contributes to the **tympanic plexus** located on the promontory (medial wall of the middle ear), which is deeper and less likely to be injured by a superficial penetration compared to the chorda tympani. * **Lesser petrosal nerve:** This is a continuation of the tympanic plexus carrying preganglionic parasympathetic fibers to the otic ganglion. It exits the middle ear through the tegmen tympani and is not in direct contact with the tympanic membrane. **Clinical Pearls for NEET-PG:** * **Clinical sign of injury:** Damage to the chorda tympani results in a **metallic taste** or loss of taste on the ipsilateral anterior 2/3rd of the tongue. * **Anatomical Landmark:** It passes through the **Iter chordae anterius** (canal of Huguier) to exit the middle ear. * **Trauma:** In cases of longitudinal temporal bone fractures, the chorda tympani is frequently involved.

Q: What is the investigation of choice for cholesteatoma?

HRCT temporal bone. **Explanation:** **Cholesteatoma** is a destructive, non-neoplastic lesion characterized by the presence of keratinizing squamous epithelium within the middle ear or mastoid. **Why HRCT Temporal Bone is the Investigation of Choice:** High-Resolution Computed Tomography (HRCT) of the temporal bone is the gold standard for evaluating cholesteatoma. It provides superior bone detail, allowing for the precise assessment of: * **Bony Erosion:** Specifically of the scutum (often the earliest sign), ossicular chain, and mastoid air cells. * **Extent of Disease:** It maps the involvement of the attic, antrum, and middle ear cleft. * **Complications:** It identifies dehiscence of the fallopian canal (facial nerve), tegmen tympani (risk of intracranial spread), and the lateral semicircular canal (fistula). **Analysis of Incorrect Options:** * **A & C (X-rays):** Conventional radiography (Schuller’s or Lateral views) has been largely replaced by CT. While they can show mastoid pneumatization or large areas of destruction, they lack the sensitivity to detect early cholesteatoma or soft tissue extensions. * **B (Otoscopy):** While otoscopy is the **initial clinical step** and may show a retraction pocket or pearly white mass, it cannot determine the depth of the lesion or the extent of bony destruction behind the tympanic membrane. **High-Yield Clinical Pearls for NEET-PG:** * **Earliest Bony Change:** Erosion of the **scutum** (outer attic wall). * **MRI (Non-EPI Diffusion Weighted):** This is the investigation of choice for detecting **recurrent or residual** cholesteatoma post-surgery, as it can differentiate between fibrous tissue/granulation and keratin. * **Clinical Sign:** A "marginal perforation" or "attic perforation" with foul-smelling discharge is classically associated with cholesteatoma.

Q: Medical treatment is not effective in which type of otitis media?

Secretory otitis media. **Explanation:** The correct answer is **Secretory Otitis Media (SOM)**, also known as Otitis Media with Effusion (OME). **Why Secretory Otitis Media?** The primary pathophysiology of SOM is **Eustachian tube dysfunction**, leading to negative middle ear pressure and the accumulation of sterile, non-purulent fluid. Unlike bacterial infections, SOM is **not an active inflammatory or infectious process** that responds to antibiotics. Medical management (decongestants, antihistamines, or steroids) has been proven largely ineffective in resolving the effusion. The definitive treatment is surgical: **Myringotomy with Grommet insertion**, which provides ventilation and equalizes pressure. **Analysis of Incorrect Options:** * **Tuberculous Otitis Media:** This is a chronic bacterial infection caused by *Mycobacterium tuberculosis*. It is treated medically with standard **Anti-Tubercular Therapy (ATT)**. * **Acute Suppurative Otitis Media (ASOM):** This is an acute bacterial infection (commonly *S. pneumoniae*). It responds excellently to **systemic antibiotics** (like Amoxicillin) and nasal decongestants. * **Chronic Suppurative Otitis Media (CSOM):** While the mucosal type (Tubotympanic) often requires surgery for permanent cure (Myringoplasty), the active infection is managed medically with **topical antibiotic ear drops** and aural toilet to achieve a "dry ear." **NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis for SOM:** Impedance Audiometry (Tympanometry) showing a **Type B (Flat) curve**. * **Most common cause of SOM in children:** Adenoid hypertrophy. * **Unilateral SOM in an adult:** Must rule out **Nasopharyngeal Carcinoma** (biopsy of Fossa of Rosenmüller). * **Grommet placement:** Usually done in the **Antero-inferior quadrant** of the tympanic membrane to avoid injury to ossicles.

Question 1

Which of the following statements are true about otitis media with effusion in a child?

Accepted Answer

A Type B tympanogram is observed.

Answer

Immediate myringotomy is performed.

Answer

The effusion in the middle ear is sterile.

Answer

It is the most common cause of deafness in children in daycare.

Question 2

What is the appropriate treatment for an acute stable hematoma of the pinna of the ear?

Accepted Answer

Incision, drainage, and pressure bandage

Answer

Ice packs and prophylactic antibiotics

Answer

Excision of the hematoma

Answer

Needle aspiration

Question 3

Hyperacusis is seen in all of the following conditions except:

Accepted Answer

Otosclerosis

Answer

Exposure to loud sounds

Answer

Meniere's disease

Answer

Severe head injury

Question 4

What is the characteristic of glue ear?

Accepted Answer

Painless

Answer

Painful

Answer

Naf is useful

Answer

Radical mastoidectomy is required

Question 5

What is the angle made by the tympanic membrane with the floor of the external auditory meatus?

Accepted Answer

55 degrees

Answer

35 degrees

Answer

75 degrees

Answer

90 degrees

Question 6

What is the commonest causative organism for acute suppurative otitis media (ASOM) in a 2-year-old child?

Accepted Answer

Streptococcus pneumoniae

Answer

Streptococcus pyogenes

Answer

Staphylococcus aureus

Answer

Haemophilus influenzae

Question 7

A boy with acute suppurative otitis media (ASOM) is undergoing treatment with penicillin therapy for 7 days. He now presents with subsidence of pain and persistence of deafness. What is the most likely diagnosis?

Accepted Answer

Secretory otitis media

Answer

Ototoxicity

Answer

Adhesive otitis media

Answer

Tympanosclerosis

Question 8

A 3-year-old girl ruptured her eardrum when she inserted a pencil into her ear. Her mother took her to the emergency department after noticing that the child was crying and complaining of pain in her ear with a few drops of blood in the external auditory meatus. The attending doctor examined the child for possible injury to a nerve that runs across the eardrum. Which is the MOST likely nerve to be injured?

Accepted Answer

Chorda tympani

Answer

Auricular branch of the vagus

Answer

Glossopharyngeal nerve (CN IX)

Answer

Lesser petrosal nerve

Question 9

What is the investigation of choice for cholesteatoma?

Accepted Answer

HRCT temporal bone

Answer

Schuller's view X-ray

Answer

Otoscopy

Answer

Skull X-ray, lateral view

Question 10

Medical treatment is not effective in which type of otitis media?

Accepted Answer

Secretory otitis media

Answer

Tuberculous otitis media

Answer

Acute suppurative otitis media

Answer

Chronic suppurative otitis media

Diseases of the Ear — MCQs

Diseases of the Ear — MCQs

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