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EN4.{1-2,5,9} | Ear Symptoms and External Ear Disorders — Practice Quiz
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A 38-year-old woman presents with left ear pain of two weeks' duration. Otoscopy reveals a normal tympanic membrane. She also complains of jaw pain and clicking on chewing. Which of the following best explains the normal otoscopic finding in the presence of ear pain?
Correct. The auriculotemporal nerve (a branch of V3/mandibular division of the trigeminal nerve) innervates both the TMJ and the external ear canal. TMJ dysfunction (Costen's syndrome) is therefore a classic cause of referred otalgia with a completely normal otoscopic picture — the ear pain is genuine, but its source is extra-auricular.
Referred otalgia occurs because the ear shares sensory innervation with multiple distant structures. The auriculotemporal nerve (V3) supplies both the TMJ and the external ear — TMJ dysfunction therefore classically presents with ear pain and a normal otoscopic examination.
A normal tympanic membrane makes acute otitis media unlikely (AOM presents with a bulging, injected drum). Otitis externa would show EAC oedema/discharge and tragal tenderness. SNHL does not cause otalgia. The key clue here is jaw clicking + normal otoscopy = referred otalgia.
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Which cranial nerves contribute sensory fibres to the external ear and are therefore relevant to understanding referred otalgia? Select the COMPLETE and CORRECT set.
Correct. The external ear and related structures receive contributions from five sources: the auriculotemporal nerve (V3) from the TMJ region, Arnold's branch of VII (and auricular branch of X) supplying the EAC/concha, Jacobson's branch of IX innervating the middle ear and eustachian tube, and the great auricular nerve (C2–C3) from the cervical spine and parotid region.
Five neural pathways innervate the ear: (1) V3 auriculotemporal — from TMJ/teeth; (2) VII (Arnold's branch to EAC) — from larynx; (3) IX Jacobson's nerve — from pharynx/tonsil; (4) X Arnold's nerve — from larynx/oesophagus; (5) C2–C3 great auricular — from cervical spine. This explains the diverse extra-auricular sources of referred otalgia.
V1 and V2 do not supply the external ear. VIII is the vestibulocochlear nerve — it is sensory for hearing and balance but not for pain. XII is the hypoglossal (purely motor). The correct set is V3, VII (Arnold's), IX (Jacobson's), X (Arnold's auricular), and C2–C3.
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A 70-year-old diabetic man presents with severe left ear pain, purulent discharge, and exposed bone in the external auditory canal. Facial nerve palsy develops on day 3. Which diagnosis is MOST likely?
Correct. Malignant (necrotising) otitis externa begins as Pseudomonas OE in a diabetic/immunocompromised host and spreads through the fissures of Santorini into the skull base. Exposed cartilage or bone at the EAC floor (tympanosquamous suture) combined with facial nerve palsy is the hallmark. Facial nerve palsy occurs in ~20% of cases and worsens the prognosis significantly.
Malignant (necrotising) otitis externa is a life-threatening Pseudomonas aeruginosa infection of the EAC and skull base in elderly diabetic/immunocompromised patients. The triad: diabetic + severe OE not responding to treatment + granulation tissue/exposed bone at the EAC floor junction with facial nerve palsy = MOE until proven otherwise.
CSOM complications typically arise from the middle ear (not EAC bone exposure). Ramsay Hunt causes vesicles on the auricle + facial palsy but not bone exposure in the EAC. Squamous cell carcinoma is possible but rare; the acute presentation in an elderly diabetic strongly favours MOE. The combination of diabetes + EAC bone + facial palsy = MOE.
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On otoscopic examination of a patient with ear discharge, you note a central perforation of the tympanic membrane with mucopurulent discharge, intact ossicular chain on probing, and no cholesteatoma. How should you classify this CSOM?
Correct. Tubotympanic (safe) CSOM has a central perforation (within the pars tensa), mucosal-type disease, and no cholesteatoma. The 'safe' label reflects the low risk of life-threatening intracranial complications compared with the atticoantral type. Management is medical (aural toilet, topical antibiotics) with tympanoplasty once dry.
CSOM classification: tubotympanic (mucosal/safe) type = central perforation, mucopurulent discharge, no cholesteatoma, few complications — medical management initially; atticoantral (squamosal/unsafe) type = attic or marginal perforation + cholesteatoma + bone erosion + high complication risk → requires surgery.
The atticoantral/unsafe type has an attic or marginal perforation and cholesteatoma with bone erosion — this patient has a central perforation with no cholesteatoma. Duration >3 weeks and a perforated drum rules out ASOM. Serous OM presents with an intact effusion-filled drum, not a central perforation.
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A 14-year-old boy is brought with a two-month history of left ear discharge. Otoscopy reveals an attic perforation with a whitish, pearly mass visible in the attic. What is the MOST appropriate next step?
Correct. Cholesteatoma (atticoantral unsafe CSOM) must be surgically removed. Medical treatment (antibiotics, drops) does not eradicate cholesteatoma and allows continued bone erosion. Mastoidectomy (modified radical or combined approach tympanoplasty) is the standard surgical option.
An attic perforation with a pearly white mass = cholesteatoma = atticoantral (unsafe) CSOM. This carries a high risk of bone erosion and intracranial complications. Medical treatment is NOT appropriate; surgical removal via mastoidectomy is the definitive management.
Antibiotic drops or oral antibiotics control infection temporarily but do not treat cholesteatoma — the pearly white mass will continue to erode bone and risk intracranial complications. While CT temporal bone is a useful pre-operative investigation, it does not replace surgical management as the next definitive step.
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During myringotomy for acute suppurative otitis media at the suppuration stage, in which quadrant of the tympanic membrane should the incision be made?
Correct. The anteroinferior quadrant is the safe zone for myringotomy. The posterosuperior quadrant is avoided because it lies close to the ossicles (especially the long process of the incus and stapedial head) and the chorda tympani nerve. The posteroinferior quadrant risks injury to an aberrant/high-riding jugular bulb.
Safe myringotomy site = anteroinferior quadrant. This avoids: (1) posterosuperior — ossicles (incudostapedial joint), chorda tympani; (2) posteroinferior — aberrant jugular bulb; (3) anterosuperior — malleus handle, Eustachian tube. Anteroinferior = safest zone with lowest risk of structural injury.
The posterosuperior quadrant risks ossicular and chorda tympani injury. The posteroinferior quadrant risks jugular bulb injury. The anterosuperior quadrant lies near the malleus handle and the eustachian tube opening — the anteroinferior quadrant is consistently described as the safest site in Dhingra.
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A 45-year-old woman presents with sudden-onset episodic vertigo lasting 20–30 minutes, associated with fluctuating low-frequency sensorineural hearing loss, tinnitus, and aural fullness in the left ear. Which condition does this clinical triad most likely represent?
Correct. Meniere's disease is characterised by the tetrad of episodic vertigo (lasting minutes to hours), sensorineural hearing loss (initially low-frequency and fluctuating), tinnitus, and aural fullness — caused by endolymphatic hydrops in the membranous labyrinth. This cluster of symptoms in a middle-aged woman is classic.
Meniere's disease triad: episodic vertigo (minutes to hours) + sensorineural hearing loss (low-frequency, fluctuating) + tinnitus ± aural fullness. Caused by endolymphatic hydrops. Distinguish from BPPV (seconds, positional, Dix-Hallpike positive, NO hearing loss) and vestibular neuritis (single prolonged episode, no hearing loss).
BPPV presents with brief (seconds to <1 minute) vertigo triggered by head position change; Dix-Hallpike test is positive; there is NO associated hearing loss. Vestibular neuritis is a single acute prolonged episode (hours to days) of vertigo without hearing loss. Acoustic neuroma typically causes gradual asymmetric SNHL and tinnitus, with vertigo only in advanced cases.
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A 50-year-old man presents with three weeks of right ear discharge, tinnitus, and hearing loss. Otoscopic examination reveals an attic retraction pocket with a whitish keratinous mass and a foul smell. Which investigation is MOST useful to assess the extent of bone destruction before surgical planning?
Correct. HRCT of the temporal bone (fine-cut axial and coronal images) is the pre-operative investigation of choice for cholesteatoma. It defines the extent of bone erosion — ossicular destruction, facial canal dehiscence, tegmen plate erosion, sigmoid sinus proximity, and labyrinthine fistula — all critical for surgical planning.
Cholesteatoma (atticoantral unsafe CSOM) requires pre-operative HRCT temporal bone to map the extent of bone erosion (ossicles, tegmen, facial canal, lateral sinus, semicircular canals) before mastoidectomy. CT shows soft tissue mass and bony erosion better than MRI; MRI (DWI) is used post-operatively to detect residual/recurrent cholesteatoma.
Pure tone audiometry characterises the type and degree of hearing loss (useful but does not show bone erosion). Tympanometry in a perforated drum gives a type B flat curve — useful for diagnosis but not for extent of bone destruction. MRI is useful for detecting residual cholesteatoma post-operatively (DWI sequence) but CT is preferred pre-operatively for bony anatomy.
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A 45-year-old woman attends a general practice clinic with progressive hearing loss in both ears for six months. She reports that ear syringing was performed three months ago. Otoscopic examination now reveals impacted brown cerumen bilaterally. What is the SAFEST and most appropriate method of wax removal when the patient has a history of previous eardrum perforation?
Correct. In a patient with a history of previous perforation (even if currently healed), syringing is contraindicated — water entry through a residual micro-perforation or a newly reopened drum causes acute otitis media. Dry micro-suction under direct microscopic vision or careful dry instrumentation with a Jobson-Horne probe are the safe alternatives.
Ear syringing is CONTRAINDICATED in: (1) history of perforation or grommets, (2) only hearing ear, (3) history of ear surgery, (4) severe otitis externa. In these situations, micro-suction or dry instrumentation under direct vision is the safe method. A thorough history before any wax removal procedure is mandatory.
Ear syringing is absolutely contraindicated with a history of perforation. Ceruminolytics alone may not fully clear impacted wax and do not address the contraindication to syringing. Softening with olive oil is a useful adjunct but requires formal clearance under direct vision when syringing is contraindicated.
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A 60-year-old man with a six-week history of left ear pain and fullness is referred from a dental clinic where his tooth extraction did not relieve his symptoms. On careful examination, otoscopy is normal but a hard mass is palpated in the parotid region. Which mechanism of otalgia is demonstrated in this case?
Correct. The auriculotemporal nerve (V3) innervates both the TMJ region and the EAC/auricle, and the parotid gland also receives fibres via this nerve. A parotid mass (including parotid carcinoma, pleomorphic adenoma) can produce referred otalgia through V3. The key clinical point: otalgia persisting after dental treatment in an adult with a normal ear demands imaging to exclude head and neck malignancy.
Adult persistent otalgia with a normal otoscopic examination requires a systematic search for referred sources. The parotid gland is innervated by the auriculotemporal nerve (V3) and the great auricular nerve (C2-C3) — a parotid tumour can therefore cause referred ear pain. Persistent otalgia in an adult with a normal drum must NEVER be dismissed; exclude nasopharyngeal, parotid, and laryngeal malignancy.
A normal otoscopy makes primary otogenic pain unlikely. Arnold's branch (vagus) refers pain from the larynx and oesophagus — there is no laryngeal finding here. Psychosomatic otalgia is a diagnosis of exclusion — a palpable parotid mass demands urgent investigation. Never dismiss adult persistent otalgia with a normal ear without a full head and neck assessment.
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