"Otology" — Practice

Question 1

In a right-sided conductive hearing loss, the Weber test will

Accepted Answer

B

Question 2

Which feature suggests unsafe (squamosal) chronic otitis media?

Accepted Answer

C

Question 3

A patient has Rinne showing bone conduction better than air conduction in the right ear, but Weber lateralises to the left. Explain.

Accepted Answer

The two results are internally inconsistent for a right conductive loss, which would lateralise Weber to the right. This is a false negative Rinne.

The right ear has a severe sensorineural loss, so the fork placed on the right mastoid is being heard by the left cochlea through skull conduction, producing an apparent bone conduction better than air conduction on the right. Weber lateralising to the left, the better ear, exposes the error and confirms a right sensorineural loss.

Question 4

A 28-year-old woman has progressive bilateral hearing loss that worsened during pregnancy. Her drums look normal. Audiometry shows a conductive loss with a dip in bone conduction at 2 kHz. Diagnosis?

Accepted Answer

Otosclerosis. A progressive conductive loss with a normal-looking drum in a young adult woman is the classic presentation, and worsening during pregnancy is characteristic.

The dip at 2 kHz is the Carhart notch, a mechanical artefact of stapes fixation affecting bone conduction rather than true cochlear loss, and it resolves after successful stapedotomy. She may also report hearing better in noisy environments, which is paracusis Willisii. Management is a hearing aid or stapedotomy, and the choice is genuinely hers since a hearing aid carries no surgical risk.

Question 5

A patient describes attacks of vertigo lasting several hours, with fluctuating hearing loss, tinnitus and a sense of fullness in the same ear. What is the diagnosis and what does the audiogram show early?

Accepted Answer

Meniere disease. It is the condition in which vertigo, hearing loss and tinnitus occur together within the same attack, accompanied by aural fullness, with individual episodes typically lasting from twenty minutes to twelve hours.

Early in the disease the audiogram characteristically shows a low-frequency sensorineural loss that fluctuates, which distinguishes it from the high-frequency losses of presbycusis and noise damage. As the disease progresses the loss becomes flatter and more permanent.

Question 6

A 9-year-old has had scanty foul-smelling right ear discharge for a year with an attic perforation. He now has headache, fever and neck stiffness. What has happened and what is required?

Accepted Answer

Cholesteatoma with an intracranial complication, most likely meningitis. Squamosal chronic otitis media is characterised by attic or marginal defects, scanty foul discharge and progressive bone erosion through osteoclast activation.

Erosion through the tegmen tympani gives access to the middle cranial fossa, producing meningitis, extradural abscess or brain abscess. He needs urgent cross-sectional imaging, joint ENT and neurosurgical involvement, intravenous antibiotics and surgical clearance of the disease. The principle to carry is that discharge volume is inversely related to danger: profuse mucoid discharge is mucosal and safe, scanty foul discharge is squamosal and destructive.

Question 7

A 55-year-old hypertensive diabetic man wakes with severe continuous vertigo, vomiting and unsteadiness, without hearing loss. How is vestibular neuritis distinguished from a posterior circulation stroke?

Accepted Answer

By the HINTS examination, which in trained hands is more sensitive for posterior circulation stroke than early MRI.

The logic is inverted and is the point of the question. An abnormal head impulse test, with a corrective saccade, indicates a damaged peripheral vestibular apparatus and therefore favours vestibular neuritis. A normal head impulse test in a patient who remains acutely vertiginous means the periphery is working, so the lesion must be central. Direction-changing nystagmus and skew deviation likewise point centrally. His vascular risk factors raise the prior probability of stroke, so the peripheral pattern must be convincing before discharge is considered.

Question 8

A 40-year-old woke three days ago with hearing loss in one ear and tinnitus. Otoscopy is normal. Give the diagnosis and the immediate and later management.

Accepted Answer

Sudden sensorineural hearing loss, defined as a loss of at least 30 dB across three contiguous frequencies developing within 72 hours. It is an otological emergency rather than a routine referral.

Immediately, confirm with pure tone audiometry and start corticosteroids without delay, since treatment is recommended within two weeks of onset and outcomes are better the earlier it begins. Intratympanic steroid is used as salvage where systemic therapy fails or is contraindicated, for example in poorly controlled diabetes.

Later, MRI of the internal auditory meati is required to exclude vestibular schwannoma, because a meaningful proportion of these patients have a retrocochlear lesion that audiometry cannot identify. This applies even if hearing recovers.

Question 9

A 60-year-old has acute right facial weakness. The forehead moves normally on that side. A colleague plans steroids for Bell palsy. Comment.

Accepted Answer

The plan is wrong because the localisation is wrong. Forehead sparing indicates an upper motor neurone lesion, since the frontalis receives bilateral cortical input and therefore continues to function when one hemisphere is affected.

Bell palsy is a lower motor neurone palsy and involves the forehead. Preserved forehead movement points to a contralateral cortical or subcortical lesion, most commonly a stroke, and the correct pathway is urgent stroke assessment with imaging rather than corticosteroids. This single observation separates the two diagnoses at the bedside before any investigation, and it changes the destination of the patient entirely.

Practice — "Otology"

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