EN4.{1-2,5,9} | Ear Symptoms and External Ear Disorders — Graded Quiz

Correct. The auriculotemporal nerve (mandibular division of the trigeminal nerve, V3) innervates both the temporomandibular joint region and the external auditory canal/auricle. TMJ dysfunction, dental pathology, and parotid disease are the most common sources of referred otalgia via this route.

The auriculotemporal nerve (V3) supplies the TMJ and the external ear — TMJ dysfunction is the commonest cause of referred otalgia via this route. Tonsil/pharynx refers via CN IX (Jacobson's); larynx via CN X (Arnold's); cervical spine via C2–C3 (great auricular nerve).

Laryngeal referred otalgia travels via Arnold's branch of the vagus (X). Tonsillar/pharyngeal referred otalgia travels via Jacobson's nerve (IX). Cervical referred otalgia travels via the great auricular nerve (C2–C3). Each source has its own neural pathway to the ear.

Correct. A Negative Rinne test means bone conduction is heard LONGER/LOUDER than air conduction (BC > AC). This indicates a conductive hearing loss — something is blocking sound transmission through the outer or middle ear (e.g., wax, TM perforation, ossicular fixation). A Positive Rinne (AC > BC) is seen in normal hearing and sensorineural loss.

Rinne POSITIVE (AC > BC) = normal OR sensorineural loss. Rinne NEGATIVE (BC > AC) = CONDUCTIVE loss. Weber lateralises TO the conductive-loss side (more bone conduction perceived) and AWAY from SNHL side (to the better ear). Do not invert these.

Rinne POSITIVE = AC > BC (normal or SNHL). Rinne NEGATIVE = BC > AC = conductive loss. A negative Rinne does NOT indicate SNHL — in SNHL, air conduction is still better than bone conduction (so Rinne remains positive, though both are reduced). Do not confuse a false-negative Rinne (in unilateral total SNHL) with a true negative.

Correct. An attic perforation with a pearly keratinous mass = cholesteatoma = atticoantral (squamosal) type CSOM — the 'unsafe' variety. Cholesteatoma is a keratinising squamous epithelium that erodes bone through enzymatic action (collagenases). Consequences include ossicular erosion, facial nerve palsy, labyrinthine fistula, and potentially fatal intracranial complications (meningitis, brain abscess).

CSOM: Atticoantral (unsafe) type = attic or marginal perforation + cholesteatoma + bone erosion. Cholesteatoma erodes bone relentlessly and can cause: ossicular destruction, facial nerve palsy, labyrinthitis, meningitis, brain abscess. This is why it is 'unsafe' — management is ALWAYS surgical.

The tubotympanic (safe) type has a CENTRAL perforation, mucosal disease, and no cholesteatoma — its risks are primarily hearing loss and recurrent infection. The atticoantral type's risks extend far beyond ossicular discontinuity to include life-threatening intracranial spread.

Correct. The hallmark of malignant (necrotising) OE is granulation tissue or exposed bone at the bony-cartilaginous junction of the EAC floor, in an elderly diabetic. This represents Pseudomonas aeruginosa spreading from the EAC through the fissures of Santorini into the skull base. Cranial nerve palsies (VII most common) may follow. Ordinary OE does not cause bone exposure.

Malignant OE distinguisher: granulation tissue/exposed bone at the EAC floor (tympanosquamous/fissures of Santorini) in a diabetic or immunocompromised host = MOE. This represents Pseudomonas invasion through the cartilaginous fissures into the skull base — ordinary OE does not produce bone exposure.

Bilateral fungal debris (otomycosis) is a distinct entity. Pain relief with drops is not discriminating — MOE pain is characteristically disproportionately severe. Perichondritis involves the auricle with intact EAC anatomy. The specific finding in MOE is EAC floor bone exposure in a diabetic.

Correct. Meniere's disease is caused by endolymphatic hydrops — accumulation of excess endolymph in the membranous labyrinth (particularly the scala media/cochlear duct and saccule). Increased endolymphatic pressure causes episodic rupture of Reissner's membrane, exposing the perilymph compartment to potassium-rich endolymph, which temporarily paralyses vestibular and cochlear neurons.

Meniere's disease = endolymphatic hydrops: distension of the membranous labyrinth (cochlear duct + saccule mainly) by excess endolymph. This causes episodic rupture of Reissner's membrane → potassium-rich endolymph floods perilymph → temporary neural depolarisation block → vertigo + SNHL + tinnitus.

Otolith dislodgement = BPPV (benign paroxysmal positional vertigo). Viral vestibular nerve inflammation = vestibular neuritis. Autoimmune hair cell damage = autoimmune inner ear disease. Meniere's disease = endolymphatic hydrops.

Correct. The anteroinferior quadrant is the designated safe zone for myringotomy (per Dhingra and standard ENT practice). It avoids the posterosuperior quadrant (ossicles, chorda tympani nerve), the posteroinferior quadrant (high-riding jugular bulb), and the anterosuperior quadrant (malleus handle).

Myringotomy safe quadrant = anteroinferior. Posterosuperior = risk of ossicular injury (incudostapedial joint) and chorda tympani. Posteroinferior = risk of jugular bulb. Anterosuperior = malleus handle. Anteroinferior = fewest vital structures adjacent.

Posterosuperior = ossicular and chorda tympani risk. Posteroinferior = jugular bulb risk. Anterosuperior = near the malleus. Anteroinferior is the consistently recommended safe site for myringotomy.

Correct. A history of previous tympanic membrane perforation (even if apparently healed) is a contraindication to ear syringing. Directing pressurised water into the ear canal with an open (or weakened) drum can drive fluid into the middle ear, causing acute otitis media. Micro-suction or dry instrumentation is the safe alternative in this setting.

Contraindications to ear syringing: (1) known/suspected TM perforation, (2) grommet/ventilation tube in situ, (3) only hearing ear, (4) recent ear surgery, (5) severe otitis externa. Water entry through a perforation causes acute otitis media. Always take a history before syringing.

Bilateral impacted cerumen without contraindications is a standard indication for syringing. Softened cerumen after drops is easier to syringe — drops alone are not a contraindication. Age and presbycusis are not contraindications. History of perforation is the key contraindication tested here.

Correct. Pseudomonas aeruginosa is the most common organism in acute diffuse otitis externa (swimmer's ear). It thrives in warm, moist, macerated EAC skin and is responsible for ~50–60% of cases. It is also the causative organism in malignant (necrotising) otitis externa.

Acute diffuse otitis externa ('swimmer's ear'): most common organism = Pseudomonas aeruginosa (gram-negative, moisture-loving), followed by Staphylococcus aureus. Aspergillus niger = otomycosis (black-spored fungal OE). Streptococcus pneumoniae = otitis media, not OE.

Staphylococcus aureus is the second most common cause of OE and causes localised furunculosis of the EAC. Streptococcus pneumoniae predominantly causes otitis media. Aspergillus niger is a cause of otomycosis (fungal OE) presenting with black conidiophore debris — not the commonest in acute bacterial OE.

Correct. A bulging, red (injected) tympanic membrane in a febrile child with acute ear pain corresponds to the suppuration stage of ASOM. Pus under pressure distends the drum outward. At this stage, myringotomy may be considered to drain the pus and relieve pain if the drum does not perforate spontaneously.

ASOM stages: (1) Tubal occlusion — retracted drum; (2) Presuppuration — congested, injected drum with mucosal oedema; (3) Suppuration — bulging drum with pus, intense pain; (4) Resolution/perforation — spontaneous or surgical perforation → pain relief; (5) Complication — if unresolved. A bulging red drum = suppuration stage.

The tubal occlusion stage shows a retracted drum (negative pressure, no pus). The resolution stage follows perforation/treatment with gradual return to normal. Complication stage (mastoiditis, meningitis) represents failure of resolution and does not describe the initial presentation. The bulging red drum = suppuration.

Correct. In conductive hearing loss, Weber lateralises to the affected (worse) ear. The mechanism: the middle ear ossicular conduction block excludes ambient sound masking — the affected ear therefore perceives bone-conducted vibration more clearly. This is why a patient with right-sided CSOM (conductive loss) will lateralise Weber to the right.

Weber test: sound lateralises TO the ear with CONDUCTIVE loss (the affected ear 'hears more' bone conduction because ambient masking noise is absent). In SNHL, Weber lateralises to the BETTER (normal) ear. Do not invert: CHL = to affected side; SNHL = to better side.

Weber does NOT lateralise to the better ear in conductive loss — that is the pattern in sensorineural hearing loss. In SNHL, the cochlea is damaged on one side so bone-conducted sound is perceived better by the normal cochlea on the opposite side. The two patterns are mirror images: CHL → affected side; SNHL → better side.