10/31/2013

10/31/2013

Answers:

A 70 yo F w/ ho diabetes presents with painful and discharge from her L ear. On exam purulent otorrhea is appreciated, pinna is tender to palpation and granulation tissue is appreciated inside the EAC. What is the most concerning diagnosis?
A) Malignant Otitis Externa
B) Otitis Externa
C) Otitis Interna
D)Perichondritis of Auricle
E) Otomycosis

Malignant Otitis Externa is a potentially life threatening condition more commonly found in immunosuppressed patients including elderly diabetics. It can progress to osteomyelitis of bony canal or skull base. Classic findings includes granulation tissue at the junction of the bony and cartilaginous portions of EAC. Diagnose w/ bone scans and possible CT (to define extent of disease). Treat w/ long term VI abx. Gallium scan can be used to track disease. For diabetics, tight blood sugar control can aid in treatment of illness.

A pt presents with pruritus, pain and otorrhea from the right ear. Pt had been using ear drops (pt cannot remember the name) every day, twice daily for the past 6 months. How would you treat this patient?

This patient likely has otomycosis. Prolonged use of ototopic drops is a risk factor for this condition. The offending drops should be stopped and pt should be treated with acetic acid, nystatin powder. Frequent cleanings and clotrimazole can also be useful.

MC Questions:
All of the following are true regarding Aural Atresia except:
A) Due to failure of second branchial groove to form properly
B) 15% of patients have + family hx
C) Often unilateral
D) Affects M>F
E) Causes CHL

Free Response Question:
Microtia is due to abnormal development of what embryonic structure(s)?

Quick Facts:

Keloids:
-Abnormal reaction to trauma.
-Due to excessive deposition of collagen/extracellular matrix.
-Most commonly occurs after ear piercing.
-Keloids extend from original site of trauma unlike hypertrophic scars which do not.
-Most common in African Americans age 16-20.
-Can treat w/ steroid injection or excision (although risk of reformation)

10/30/2013

10/30/2013

Answers:

A 25 y/o M presents with symptoms of a right sided CHL. He endorses a sensation of fullness in that ear. On exam a mass of keratinized epithelium is noted which appears to be blocking the EAC. After removing the debris the underlying skin appears shiny, atrophic and erythematous however his CHL appears to improve. What is the most likely diagnosis?
A) Keratosis Obturans
B) Cerumen Impaction
C) Otitis Externa
D) Surfer's Ear
E) Otomycosis

Keratosis obturans is characterized by a buildup of keratinizing squamous epithelium that can obstruct the EAC. Often seen in young/middle age patients, its etiology is unknown. After removing the mass of epithelium shiny, atrophic and erythematous skin is often appreciated underneath. Treat with frequent debridements to avoid large buildups that are difficult to remove.

What is the treatment of otitis externa?

Cleaning the canal, topical abx and acetic acid (to restore acidic environment of EAC). A gauze wick can be used to allow abx to reach further medially if severe obstruction present.

MC Questions:
A 70 yo F w/ ho diabetes presents with painful and discharge from her L ear. On exam purulent otorrhea is appreciated, pinna is tender to palpation and granulation tissue is appreciated inside the EAC. What is the most concerning diagnosis?
A) Malignant Otitis Externa
B) Otitis Externa
C) Otitis Interna
D)Perichondritis of Auricle
E) Otomycosis

Free Response Question:
A pt presents with pruritus, pain and otorrhea from the right ear. Pt had been using ear drops (pt cannot remember the name) every day, twice daily for the past 6 months. How would you treat this patient?

Quick Facts:

Microtia
-Due to malformation of 1st/2nd branchial arches
-Can be bilateral or unilateral.
-Reconstruction is typically staged and involves harvesting costal cartilage.
-Results are often quite good.

10/29/2013

10/29/2013

Answers:

What is the most common organism to cause infectious perichondritis of the auricle?

A) Staph
B) Pseudomonas
C) Strep
D) Candida
E) Moraxella

Pseudomonas is the most common bacteria to cause perichondritis of the auricle.

At what temperature is sensory nerve conduction blocked? What is the treatment for frostbite?

<10 degrees C or <50 degrees F. Consider this when treating pts for frostbite to ears/nose/face as patients will often not feel pain until skin rewarms. Treatment for frostbite involves quickly rewarming the tissue, but avoid rubbing as this can lead to further tissue damage.

MC Questions:
A 25 y/o M presents with symptoms of a right sided CHL. He endorses a sensation of fullness in that ear. On exam a mass of keratinized epithelium is noted which appears to be blocking the EAC. After removing the debris the underlying skin appears shiny, atrophic and erythematous however his CHL appears to improve. What is the most likely diagnosis?
A) Keratosis Obturans
B) Cerumen Impaction
C) Otitis Externa
D) Surfer's Ear
E) Otomycosis

Free Response Question:
What is the treatment of otitis externa?

Quick Facts:

The most common organisms to cause otomycosis include aspergillus niger, Mucoraceae, dermatophytes and actinomyces.

10/28/2013

10/28/2013

Answers:

Management of an auricular hematoma involves all of the following except.
A) Drain via incision of helical sulcus
B) Place a drain to prevent fluid from collecting
C) Dental roll/prolene dressing left in place x 4 weeks
D) Antistaphylococcal abx
E) Drain via incision of antihelical fold

An auricular hematoma can be drained via a helical sulcus or antihelical fold incision depending on location of hematomas. Abx should be used and a drain can sometimes be used to drain fluid. A dental roll with nonabsorbable suture should be used to apply pressure to the incision site however this dressing is only left in place 7-10 days.

The first branchial arch gives rise to the first 3 hillocks which become---,---,---. the second branchial arch gives rise to the second 3 hillocks which become ---,---,---.

1st branchial arch = tragus, helical crus and helix
2nd branchial arch = antihelix, scapha and lobule

MC Questions:

What is the most common organism to cause infectious perichondritis of the auricle?

A) Staph
B) Pseudomonas
C) Strep
D) Candida
E) Moraxella

Free Response Question:
At what temperature is sensory nerve conduction blocked? What is the treatment for frostbite?

Quick Facts:

Otitis Externa (aka swimmer's ear)
-Pathogens grow best in EAC when alkaline conditions present which often happens after retention of water.
-Trauma can induce infection (cerumen removal, presence of foreign body, scratching canal skin)
-Common pathogens: pseudo. Staph and strep can play a role as well.
-Present with severe otalgia, erythema, edema and purulent otorrhea.
-Treat by cleaning EAC w/ suction, topical abx and acetic acid drops.
-Use gauze wick if sever obstruction present.

10/25/2013

10/25/2013

Answers:

Wave II in the following image corresponds to signal transduction through what structure?

A) Lateral lemniscus 
B) Brainstem 
C) Cochlear Nucleus 
D) Peripheral CNVIII 
E) Central CNVIII

This image represents a normal ABR. 
Wave I – generated by the peripheral portion of cranial nerve VIII
Wave II – generated by the central portion of cranial nerve VIII
Wave III – generated by the cochlear nucleus
Wave IV – generated by the superior olivary complex/lateral lemniscus
Wave V – generated by the lateral lemniscus/inferior colliculus

What is the primary use of CHAMP?

Cochlear Hydrops Analysis Masking Procedure is used primarily for detecting Meniere disease.

MC Questions:
Management of an auricular hematoma involves all of the following except.
A) Drain via incision of helical sulcus
B) Place a drain to prevent fluid from collecting
C) Dental roll/prolene dressing left in place x 4 weeks
D) Antistaphylococcal abx
E) Drain via incision of antihelical fold

Free Response Question:
The first branchial arch gives rise to the first 3 hillocks which become---,---,---. the second branchial arch gives rise to the second 3 hillocks which become ---,---,---.

Quick Facts:

Perichondritis of Auricle
-Often due to trauma (wrestling, lac or ear piercing)
-Infections perichondritis most often due to pseudomonas.
-Treat w/ I&D and/or Abx.
-May involve ear lobule.
-Can also be caused by inflammatory process = relapsing polychondritis.
-Associated with other autoimmune diseases and involves cartilages of nose, neck and chest.
-Treat w/ steroids/pain control.
-Ear lobule not involved in relapsing polychondirits.

10/24/2013

10/24/2013

Answers:

If the following tympanogram was accompanied by an elevated EAC volume what would the likely diagnosis be?

A) Otosclerosis
B) Ossicular discontinuity
C) Middle ear effusion
D) TM perforation
E) Eustachian tube dysfunction

This is a Type B tympanogram which indicates either a middle ear effusion or a TM perforation. The tympanogram is flat because there is a lack of compliance. If the middle ear has an effusion, then the TM is noncompliant due to resistant from the fluid, but EAC volume should be normal. However, in a perf the TM is noncompliant because pressure applied to the tympanogram is simply transferred into the middle ear and out the eustachian tube. EAC volume will be elevated because the volume of the middle ear is counted in this total due to communication via the perf. Eustachian tube dysfunction is indicated by a Type C tympanogram which has negative peak pressure. Otosclerosis and Ossicular discontinuity are indicated by Type As and Ad tympanograms respectively.

If acoustic reflex testing is performed and the pt only has an ipsilateral reflex of the left ear, what would be the most likely explanation for these findings?

A severe CHL in the right ear. No acoustic reflex is elicited when the CHL ear is stimulated as the signal is not intense enough to trigger it. Additionally, you may not always see a contralateral reflex if the normal hearing ear is stimulated if the middle ear pathology of the CHL ear involves the stapedius and prevents it from contracting. Thus, in severe CHL only the ipsilateral reflex of the normal hearing ear is present.

MC Questions:
Wave II in the following image corresponds to signal transduction through what structure?

A) Lateral lemniscus 
B) Brainstem 
C) Cochlear Nucleus 
D) Peripheral CNVIII 
E) Central CNVIII

Free Response Question:
What is the primary use of CHAMP?

Quick Facts:

Otoacoustic Emissions
-Objective, noninvasive, rapid measures of cochlear hair cell function.
-Byproduct of biomechanical motility
-Good probe fit and low ambient noise necessary.
-OAE detected in normal/near-normal hearing.
-Not detected if CHL/SNHL of 25-30 db or greater.
-Even middle ear pathology will eliminate OAE as stimulation intensity is decreased and signal cannot travel back to microphone.
-3 types = spontaneous, transient evoked and distortion

10/23/2013

10/23/2013

Answers:

An individual who has difficulty with soft or distant sound but understands most speech without cues and appreciates environmental sounds would likely have what type of hearing loss.
A) Mild (25-50db)
B) Moderate (50-70db)
C) Severe ( 70-90db)
E) Profound (90+)

Mild (25-50db) = difficulty w/ soft soft/distant sound
Moderate (50-70db) = diff w/ normal conversation level, need visual cues
Severe ( 70-90db) = misses all speech, can hear environmental sound
Profound (90+) = hears only airplanes/jackhammers etc.

What is the Stenger test? What is it used for?

Stenger test = when both ears are stimulated at the same time by an equal frequency and phase, the better hearing ear should perceive the sound. This can be used to detect pseudohypoacusis (fake/exaggerated hearing loss)

MC Questions:
If the following tympanogram was accompanied by an elevated EAC volume what would the likely diagnosis be?

A) Otosclerosis
B) Ossicular discontinuity
C) Middle ear effusion
D) TM perforation
E) Eustachian tube dysfunction

Free Response Question:
If acoustic reflex testing is performed and the pt only has an ipsilateral reflex of the left ear, what would be the most likely explanation for these findings?

Quick Facts:

Auditory Brainstem Response
-Objectively assess CNVIII to midbrain.
-Electrodes are placed on pt head and sounds are presented.
-30-60min
-5-7 waves occur within 10-15 ms.
-Waves I/II = in CNVIII
-Waves III-V = brainstem/midbrain
-Latencies and amplitudes of I, III and V are analyzed
-Can also use for auditory threshold.
-lowest intensity at which wave V is seen is considered threshold.
-often used in newborns
-CHAMP = cochlear hydrops analysis masking procedure = used for detecting Meniere disease.

10/22/2013

10/22/2013

Answers:

What is the definition of "Hearing Threshold"?
A) Minimum frequency that is detectable 100% of the time
B) Minimum intensity that is detectable 100% of the time
C) Minimum frequency that is detectable 50% of the time
D) Minimum intensity that is detectable 50% of the time
E) Minimum frequency that is detectable on exam
F) Minimum intensity that is detectable on exam

Threshold = softest intensity of pure tone detected 50% of the time.

What is "Masking" and why is it used?

Masking is used because a noise given to one ear can often be heard on the other side. To prevent a nontest ear from hearing a sound presented to the tested ear, a noise is presented to the nontest ear to "distract" it and prevent it from responding to the test sound. This is called masking. Masking is needed for AC whenever AC-BC gap is 40db(for lower freq) or 60db(for high freq). Masking is needed for BC whenever an AC-BC gap occurs.

MC Questions:
An individual who has difficulty with soft or distant sound but understands most speech without cues and appreciates environmental sounds would likely have what type of hearing loss.
A) Mild (25-50db)
B) Moderate (50-70db)
C) Severe ( 70-90db)
E) Profound (90+)

Free Response Question:
What is the Stenger test? What is it used for?

Quick Facts:

Acoustic Reflex
-When the stapedius muscle contracts due to loud sound.
-Occurs at 70-90db above pts hearing threshold.
-Can measure reflex by measuring change in compliance after loud sound.
-Monaural stimulation causes b/l muscle contract so can measure ipsi or contra.
-R ipsi = stimulus r ear, probe r ear
-R contra = stimulus r ear, probe l ear
-L ipsi = stimulus l ear, probe l ear
-L contra = stimulus l ear, probe R ear.
-Mild/mod SNHL = contra and ipsi reflex are at same levels
-Sev/profound SNHL = acoustic reflexes absent.
-Large CHL = eliminates response to both ears when affected ear stimulated. When good ear stimulated may not get contra due to pathology of middle ear preventing stapedius contraction.
-Only reflex in unilateral CHL = ipsi reflex of normal ear.
-CN VIII lesions = eliminated reflex both contra and ipsi when affect side stimulated.
-path of central crossed pathways = both ipsi present, contra missing.
-VII lesion (Bell's palsy) = no reflex on affected side regardless of side stimulated, but only true id lesion is proximal to branch to stapedius muscle.

10/21/2013

10/21/2013

Answers:

Postoperative surgical risks for cochlear implants include all of the following except...
A) Extrusion of implant
B) Meningitis
C) Perilymphatic gusher
D) Damage to CNVII
E) Vertigo
F) All of the above

Perilymphatic gusher is an intraoperative complication and usually occurs in the presence of Mondini malformation (cochlear malformation resulting in 2 or less turns. Other intraop complications include partial insertion of electrode, insertion trauma (through basilar membrane or fx of osseous spiral lamina).

What imaging modality is contraindicated in patients with cochlear implants.

MRI is contraindicated due to concerns over implant movement. However this is changing. Several companies have approved CIs in 0.2 teslas machines and a nonmagnetic version of CIs are available if pt is expected to require repeat MRI imaging for a CNS disease.

MC Questions:
What is the definition of "Hearing Threshold"?
A) Minimum frequency that is detectable 100% of the time
B) Minimum intensity that is detectable 100% of the time
C) Minimum frequency that is detectable 50% of the time
D) Minimum intensity that is detectable 50% of the time
E) Minimum frequency that is detectable on exam
F) Minimum intensity that is detectable on exam

Free Response Question:
What is "Masking" and why is it used?

Quick Facts:

Categories of hearing loss:
0-25 = normal
25-50 = mild HL; difficulty w/ soft soft/distant sound
50-70 = mod HL; diff w/ normal conversation level, need visual cues
70-90 = severe HL; misses all speech sound, can hear environmental sound
90+= profound HL; hears only airplanes/jackhammers etc.

10/18/2013

10/18/2013

Answers:

Cochlear implants are indicated for pts who meet all of the following criteria except...
A) Pt is at least 12 months old
B) Binaural severe SNHL
C) Binaural profound SNHL
D) Intact CNVIII
E) Prior success with hearing aids.
F) All of the above

Cochlear implants are indicated in pts at least 12 months old w/ binaural severe-profound hearing loss with intact CNVIII and hx of minimal benefit with hearing aids.

What are the three sites for cochlear implant electrode placement?

-Intrachochlear (in scala tympani)
-Extracochlear ( in promontory/round window)
-Intraneural (directly on modiolus)

MC Questions:
Postoperative surgical risks for cochlear implants include all of the following except...
A) Extrusion of implant
B) Meningitis
C) Perilymphatic gusher
D) Damage to CNVII
E) Vertigo
F) All of the above

Free Response Question:
What imaging modality is contraindicated in patients with cochlear implants.

Quick Facts:

Cochlear implant sounds are not like normal hearing. Initially, they only allowed the detection of noise but pts were unable to understand speech. As improvements have been made many patients are able to understand speech with the assistance of visual cues and some can even use the telephone however large variability exists in response to these implants.

10/17/2013

10/17/2013

Answers:

Which of the follow is not an advantage of completely in the canal hearing aids?
A) Barely noticeable 
B) Less occlusion effect 
C) Less feedback with jaw movement 
D) Easier to use with telephones 
E) Less wind-noise problem

CIC hearing aids actually have increased feedback from jaw movement.

What are two ways hearing aids can be stopped from amplifying sound to an uncomfortable level.

Peak Clipping = Creates distortion when hearing aid is in saturation. 
Compression = As the hearing input increases the amount of gain is automatically reduced to avoid reaching painful level.

MC Questions:
Cochlear implants are indicated for pts who meet all of the following criteria except...
A) Pt is at least 12 months old
B) Binaural severe SNHL
C) Binaural profound SNHL
D) Intact CNVIII
E) Prior success with hearing aids.
F) All of the above

Free Response Question:
What are the three sites for cochlear implant electrode placement?

Quick Facts:

Complications of Cochlear Implants
-Intraop:
-Partial insertion (ossified cochlea)
-Insertion trauma (penetration through basilar membrane or fx of osseous spiral lamina)
-Perilymphatic Gusher (if Mondini malformation present)
-Postop:
-Postauricular flap edema
-Necrosis (most common)
-Transient Vertigo
-Facial nerve paresis/paralysis
-Meningitis
-Extrusion of implant

10/16/2013

10/16/2013

Answers:

Which of the following is not one of the components in a typical hearing aid?

A) Receiver
B) Volume Control 
C) Battery
D) Amplifier 
E) Converter 
F) Microphone

The five components of a hearing aid is a microphone, amplifier, receiver, volume control and battery.

Define: 
-Saturation sounds pressure level 
-Acoustic Gain 
-Output Limiting 
-Frequency Gain Response

-Saturation Sound Pressure Level = maximum amount of sound pressure output a hearing aid can make. 
-Acoustic Gain = difference in output relative to input of a hearing aid. 
-Output limiting = maximum intensity of amplified signal. 
-Frequency Gain response = amount of gain as a function of frequency.

MC Questions:
Which of the follow is not an advantage of completely in the canal hearing aids?
A) Barely noticeable 
B) Less occlusion effect 
C) Less feedback with jaw movement 
D) Easier to use with telephones 
E) Less wind-noise problem

Free Response Question:
What are two ways hearing aids can be stopped from amplifying sound to an uncomfortable level.

Quick Facts:

Causes of " VERTIGO "

• Vascular
• Epilepsy
• Rx with antihypertensives, tranquilisers and quinine
• Tumor (acoustic neuroma), Trauma, Thyroid (hypothyroidism)
• Infection (vestibular neuronitis)
• Glial disease (multiple sclerosis)
• Ocular

10/15/2013

10/15/2013

Answers:

What is the most common cause of noise induced hearing loss (nonoccupational)

A) Rock Concerts
B) Airplanes
C) Gunfire
D)  Lawnmowers
E) Car alarms

Gunfire produces 140-170 db of noise.  The audiogram usually shows a hearing loss in the 4000hz range.  Interestingly, a right handed shooter often has left sided hearing loss.  The theory is that the right ear is somewhat protected by being tucked into the shoulder while rifle is being aimed/fired.

Name two medication categories that are ototoxic.

-Salicylates
-Aminoglycosides
-Erythromycin
-Cis-platinum
-Loop diuretics

MC Questions:
Which of the following is not one of the components in a typical hearing aid?

A) Receiver
B) Volume Control 
C) Battery
D) Amplifier 
E) Converter 
F) Microphone

Free Response Question:
Define: 
-Saturation sounds pressure level 
-Acoustic Gain 
-Output Limiting 
-Frequency Gain Response

Quick Facts:
7 types of hearing aids: 
-behind the ear 
-in the canal 
-body aids 
-in the ear 
-completely in the canal 
-contralateral routing of sound/bilateral aids