11/29/2013

11/29/2013

Answers:

What type of tympanogram is expected as otosclerosis progresses?
A) Type Ad 
B) Type As 
C) Type B 
D) Type C 
E) Otosclerosis does not affect tympanograms

A type As tympanogram is expected in advanced otosclerosis. As the stapes becomes progressively fixated, the TM becomes less compliant and there is blunting of the tympanogram.

What is the earliest sign of otosclerosis?

Absent acoustic reflexes are the earliest signs of otosclerosis.

MC Questions:
All of the following increase the risk of perilymphatic gusher's during stapedectomy except...
A) Meniere's Disease 
B) Mondini malformation 
C) Enlarged Vestibular Aqueduct Syndrome 
D) Congenitally Fixed Footplate

Free Response Question:
What are three nonsurgical treatment options for otosclerosis?

Quick Facts:

Pathogenesis of SNHL
-cochlear neurons send fibers bilaterally to auditory nuclei in midbrain→ signals through medial geniculate thalamic nuclei→ auditory cortex in superior temporal gyri
-Intensity of sound encoding be three things:
-amount of neural activity in individual neuron
-the number of neurons active
-specific neurons activated
-2/3rds of hereditary hearing impairments are nonsyndromic
-70-80% of nonsyndromic HHI is inherited as AR.
-Hearing loss associated with dominant genes has onset in adolescence/adulthood (varies in severity).
-Hearing loss associated with recessive inheritance is congenital and
profound.
-Common syndromic forms of hearing loss include:
-Usher Syndrome = retinitis pigmentosa
-Waardenburg = pigmentary abnormality
-Pendred = thyroid organification defect
-Alport Syndrome = renal disease
-Jervell/Lange-Nielsen syndrome = prolonged QT interval

11/28/2103

11/28/2013

Answers:

On physical exam, a patient w/ otosclerosis may demonstrate a reddish blush over the promontory and oval window niche. What causes this finding?
A) Due to an effusion in the middle ear space 
B) Due to prominent vascularity associated w/ inflammation 
C) Due to bleeding from a fractured incus 
D)Due to prominent vascularity associated w/ otospongiotic focus

This findings is called the Schwartze sign. It is uncommon, but strongly predicts otosclerosis if appreciated.

Describe the significant finding of this audiogram.

This audiogram shows a "carhart notch" which is elevation of bone
conduction thresholds at 500/1000/2000 hz and is due to disruption of
normal ossicular resonance. It is highly suggestive of otosclerosis.

MC Questions:
What type of tympanogram is expected as otosclerosis progresses?
A) Type Ad 
B) Type As 
C) Type B 
D) Type C 
E) Otosclerosis does not affect tympanograms

Free Response Question:
What is the earliest sign of otosclerosis?

Quick Facts:

Nonsurgical Therapy for Otosclerosis

-Sodium Fluoride = reduces osteoclastic bone resorption and increased osteoblastic bone formation.
-also thought to inhibit proteolytic enzymes that are cytotoxic to cochlea which
can because SNHL.
-recommended in patients with new-onset otosclerosis, rapidly progressing
disease or SNHL/dizziness.
-Pts with cochlear otosclerosis may be treated indefinitely.

-Bisphosphonates
-potent antiresorptive used in osteoporosis.
-inhibit osteoclastic activity
-most common are alendronate, etidronate, risedronate and
zoledronate

Amplification
-most have normal cochlear function with good speech discrimination so they are good hearing aid candidates.
-Most patients encouraged to try hearing aids prior to surgery as risk are
low.

11/27/2013

11/27/2013

Answers:

What region is the most common area for otosclerosis to begin?

A) Anterior border of round window 

B) Fissula Ante Fenestram 

C) Scutum 

D) Posterior border of oval window

Most common region is fissula ante fenestram which is anterior to stapes footplate and the oval window

What is the "paracusis of Willis"?

The ability to hear better in noise. The patient experiences better understanding of speech in a noisy environment. This phenomenon is characteristic of all patients with conductive hearing loss (including otosclerosis); it occurs because people speak louder in noisy surroundings.

MC Questions:
On physical exam, a patient w/ otosclerosis may demonstrate a reddish blush over the promontory and oval window niche. What causes this finding?
A) Due to an effusion in the middle ear space 
B) Due to prominent vascularity associated w/ inflammation 
C) Due to bleeding from a fractured incus 
D)Due to prominent vascularity associated w/ otospongiotic focus

Free Response Question:
Describe the significant finding of this audiogram.

Quick Facts:

Tympanometry
-Early/middle stage otosclerosis have normal (type A) tympanogram
-Progressive stapes fixation causes Type As (A-shallow) tympanogram
Acoustic Reflex (stapedial reflex)
-abnormal acoustic reflex pattern is earliest sign of otosclerosis.
-normal acoustic reflex demonstrates sustained decrease in compliance during stimulus (due to contraction of stapedial muscle)
-In otosclerosis a biphasic “on-off” pattern with a brief increase in compliance at
onset and finish of stimulus is pathognomonic.
-With disease progression a reduction in reflex amplitude is observed followed by
ipsilateral, then contralateral thresholds and finally disappearance of the
response altogether.
-Most common finding at presentation is absent reflex.

11/26/2013

11/26/2013

Answers:

How long of a delay should there be before a "second look" procedure is performed on a canal wall up mastoidectomy?
A) 1 month 
B) 3-5 Months 
C) 6 Months 
D) 8-12 Months 
E) 1-2 years 
F) Whenever is convenient for the patient.

"second look" procedures are often performed 8-12 months after the initial surgery. Any ossicular chain reconstruction is often delayed until this time to prevent adhesion formation around the reconstruction which can affect hearing results.

What is the rate of recurrence/residual cholesteatoma after surgery?

Recurrence/residual rates vary but they can be estimated to be as high as 40% after 5 years.

MC Questions:
What region is the most common area for otosclerosis to begin?
A) Anterior border of round window 
B) Fissula Ante Fenestram 
C)Scutum 
D) Posterior border of oval window

Free Response Question:
What is the "paracusis of Willis"?

Quick Facts:

Signs and Symptoms of otosclerosis
-Hx of slowly progressive hearing loss usually bilateral and asymmetric. (30%
unilateral).
-Improved hearing w/ background noise (paracusis of Willis)-Tinnitus
is common, indicates sensorineural degeneration.
-Vertigo rare
Physical Exam
-Otoscopic exam excludes other CHL causes (cholesteatoma, tympanosclerosis, middle ear effusion/mass)
-In otosclerosis, ™ is normal, middle ear is pneumatized and malleus should
move.
-Active disease may show “Schwartze sign” = reddish blush over promontory and oval window niche due to prominent vascularity associated w/ otospongiotic 
focus.
-Weber should lateralize to ear most affected. Rinne should by negative.

11/25/2013

11/25/2013

Answers:

What is the name of the area between the pars flaccida, malleus neck and the lower portion of the malleus head.
A) Muller Region 
B) Mondini Area 
C) Facial Recess 
D) Schwarte's Space 
E) Prussak's Space

This is the area most commonly invaded by pars flaccida cholesteatomas.

During a mastoidectomy, where is it easiest to identify the facial nerve?

It is easiest to identify CNVII in the attic just anterior and inferior to the horizontal semicircular canal.

MC Questions:
How long of a delay should there be before a "second look" procedure is performed on a canal wall up mastoidectomy?
A) 1 month 
B) 3-5 Months 
C) 6 Months 
D) 8-12 Months 
E) 1-2 years 
F) Whenever is convenient for the patient.

Free Response Question:
What is the rate of recurrence/residual cholesteatoma after surgery?

Quick Facts:

Otosclerosis
-Unique to temporal bone, exclusive to otic capsule.
-abnormal removal of mature dense otic capsule be osteoclasts and replacement w/ woven bone of greater thickness, cellularity and vascularity.
-Can involve any part of bony labyrinth but tends towards region near anterior border of oval window (fissula ante fenestram).
-CHL occurs if annular ligament of oval window and stapes footplate involved.
-SNHL can occur if other parts of otic capsule involved.
-Incidence of clinical disease .5-1.0% but subclinical disease be by as high as 13%.
-Half as prevalent in Asians, 1/10 as common in AAs.
-W>M be 2:1.
-Hormonal influences in pregnancy may cause rapid progression in women.
-Average age of presentation is 20-45

11/22/2013

11/22/2013

Answers:

Why must suppurative labyrinthitis secondary to AOM be diagnosed and treated quickly?
A) to avoid CHL 
B) to avoid SNHL 
C) to avoid meningitis 
D) to avoid petrositis 
E) to avoid Meniere's disease

-Bacteria can track further to cochlear aqueduct creating conduit btwn perilymph and CSF = meningeal infiltration.
-Must dx and treat labyrinthitis quickly to prevent development of meningitis.


What is Gradenigo's Triad?

-Gradenigo’s triad = Petrositis = rare = retro orbital pain, AOM, ipsilateral abducens nerve paresis.

MC Questions:
What is the name of the area between the pars flaccida, malleus neck and the lower portion of the malleus head.
A) Muller Region 
B) Mondini Area 
C) Facial Recess 
D) Schwarte's Space 
E) Prussak's Space

Free Response Question:
During a mastoidectomy, where is it easiest to identify the facial nerve?

Quick Facts:

Cholesteatoma Prognosis
-high rate of recurrence/residual disease.
-As high as 40% after 5 years.
-For this reason regular exams over 10 years is required.

11/21/2013

11/21/2013

Answers:

What is the first line antibiotic for AOM?
A) Vancomycin 
B) Cipro 
C) Amoxicillin 
D) Keflex 
E) Imipenem

Amoxicillin is first line although Augment is often used due to high resistance to Amoxicillin.

What is a Bezold's abscess?

When infection escapes the mastoid tip it can travel down the upper neck along SCM sheath causing a Bezold’s abscess (just deep to SCM).

MC Questions:
Why must suppurative labyrinthitis secondary to AOM be diagnosed and treated quickly?
A) to avoid CHL 
B) to avoid SNHL 
C) to avoid meningitis 
D) to avoid petrositis 
E) to avoid Meniere's disease

Free Response Question:
What is Gradenigo's Triad?

Quick Facts:

Mastoidectomy Surgical Technique
-Postauricular or endaural incision
Facial Nerve
-by careful at posterior superior mesotympanum.
-horizontal facial nerve runs here.
-easiest to identify nerve at antrum and attic just anterior and inferior to horizontal semicircular canal.
Facial Recess and Epitympanum
-adequate exposure of posterio-superior mesotympanum needs dissection of facial recess.
-can do canal-wall-up or canal-wall-down
-If canal-wall-up then facial recess exposure needs to extent into attic be removing the incus buttress and incus itself.
-Epitympanum is best exposed using canal-wall-down.
Canal Wall Considerations
-Up vs. down based on several things.
-surgeon experience
-low tegmen of anterior sigmoid sinus may require canal wall down.
-possibility of recurrence/residual disease.
-canal-wall-down superior exposure but up can provide adequate exposure too.

11/20/2013

11/20/2013

Answers:

All of the following are risk factors for AOM except...
A) Parental Smoking 
B) Daycare 
C) Allergic Rhinitis 
D) Breast Feeding 
E) Craniofacial Anomalies

Breast feeding is actually protective and the absence of breast feeding is a risk factor for AOM/OME.

The acronym "COMPLETES" is often used to help guide a thorough otoscopic exam. What does "COMPLETES" stand for?

-Color
-Other
-Mobility
-Position
-Lighting
-Entire Surface
-Translucency
-EAC/Auricle
-Seal

MC Questions:
What is the first line antibiotic for AOM?
A) Vancomycin 
B) Cipro 
C) Amoxicillin 
D) Keflex 
E) Imipenem

Free Response Question:
What is a Bezold's abscess?

Quick Facts:

Petrositis
-rare
-infection spreads within temporal bone into petrous apex.
-Gradenigo’s syndrome = classic triad = rare = retro orbital pain, AOM, ipsilateral abducens nerve paresis.
-Confirm dx w/ film showing bony destruction of petrous apex.
Facial Nerve Paresis:
-two mechanisms:
-release of locally produces bacteria-mediated toxins
-direct effect of inflammatory tissue adjacent to facial nerve (as it traverses mastoid cavity)
-Difficult to pinpoint site of lesion: use emg, eng, MRI w/ gadolinium.
-In adults this is most often in cholesteatoma, in children it is most common in AOM.
Labyrinthitis:
-present w/ sudden SNHL, severe vertigo, nystagmus w/ n/v
-Caused by bacterial infection invading through round window causing suppurative labyrinthitis.
-Bacteria can track further to cochlear aqueduct creating conduit btwn perilymph and CSF = meningeal infiltration.
-Must dx and treat labyrinthitis quickly to prevent development of meningitis.

11/19/2013

11/19/2013

Answers:

How many episodes of AOM are required to diagnose "recurrent AOM"?
A) 2 in 6 months with complete resolution of symptoms 
B) 4 in six months without complete resolution of symptoms 
C) 4 in one year with complete resolution of symptoms 
D) 2 in one year without complete resolution of symptoms 
E) None of the above

Recurrent AOM = 3+ episodes in 6 months or 4+ in a year w/ complete resolution of symptoms in between episodes.

Name an example of both functional and anatomic eustachian tube dysfunction.

Functional = failure of tensor veli palatini to contract.  
Anatomic = Adenoid Hypertrophy

MC Questions:
All of the following are risk factors for AOM except...
A) Parental Smoking 
B) Daycare 
C) Allergic Rhinitis 
D) Breast Feeding 
E) Craniofacial Anomalies

Free Response Question:
The acronym "COMPLETES" is often used to help guide a thorough otoscopic exam. What does "COMPLETES" stand for?

Quick Facts:

Management of OM
-Most episodes of AOM resolve spontaneously.
-Only marginal benefit to using Abx.
-Amoxicillin is first line.
-Observation for 48hrs for fever or progressive symptoms is safe as well.
-Decongestants/vasoconstrictors/antihistamines have no impact.
-OME treated w/ observation/close follow up (if asymptomatic) or prolonged Abx (symptomatic)
-RCT show ABx indicated in OME.
-If Abx fail to improve symptoms in OME then surgical intervention is warranted.
-Abx prophylaxis for OME is unlikely to help.

11/18/2103

11/18/2013

Answers:

All of the following are true with regards to congenital cholesteatomas except...
A) Often discovered incidentally 
B) Does not usually present with TM perf 
C) Patients w/ congenital cholesteatoma tend to have well aerated mastoids 
D) Can present in anterior or posterior quadrants 
E) All of the above are true

All answer choices are true with regards to congenital cholesteatomas.

Where are congenital cholesteatomas "classically" found? What do they look like on otoscope exam?

1. "Classically” in anterosuperior quadrant of mesotympanum (27-67%)
2. Small pearls next to long process of malleus

MC Questions:
How many episodes of AOM are required to diagnose "recurrent AOM"?
A) 2 in 6 months with complete resolution of symptoms 
B) 4 in six months without complete resolution of symptoms 
C) 4 in one year with complete resolution of symptoms 
D) 2 in one year without complete resolution of symptoms 
E) None of the above

Free Response Question:
Name an example of both functional and anatomic eustachian tube dysfunction.

Quick Facts:

Pathogenesis of AOM/OME
-All forms of OM due to Eustachian tube dysfunction.
-Eustachian tube aerates middle ear and has mucociliary clearance role.
-Obstruction of eustachian tube can by functional (failure of tensor veli palatini to contract) or anatomic (adenoid hypertrophy).
-Most AOM preceded by viral infection, but bacterial component is in majority.
-Most common pathogens = Strep pneumo, H. flu, Moraxella catarrhalis.
-OME develops after untreated/unresolved AOM.
-Persistent effusion present in 40% of kids after first AOM one month later (10% @ 3 months)
-Risk factors for AOM/OME = parental smoking, absence of breast feeding, day care attendance, craniofacial anomalies, adenoid hypertrophy and allergic rhinitis.

11/15/2013

11/15/2013

Answers:

Which ossicle requires the longest period of development?
A) Incus 
B) Stapes 
C) Malleus 
D) They are all equal

The stapes requires the longest period of embryologic development. Additionally, it is derived from both branchial arch and otic capsule precursors which makes it's embryologic origins more complex. This is thought to be the reason why congenital anomalies of the stapes (40% of congenital ossicular lesions) are more common than that of either the incus or the malleus.

What does a "high riding" bulb refer to?

“High riding” bulb = jugular bulb (at junction of sigmoid sinus and inferior petrosal sinus) that rises above the inferior aspect of the bony annulus or the basal round of the cochlea.
-Present in 5% of people, may be related to poor pneumatization of mastoid.
-Can present with tinnitus, vestibular symptoms and CHL (due to compression of middle ear contents)
-Most commonly discovered incidentally on exam.
-Classically a blue mass is seen posteroinferior quadrant of TM.
-At risk of inadvertent laceration during myringotomy.

MC Questions:
All of the following are true with regards to congenital cholesteatomas except...
A) Often discovered incidentally 
B) Does not usually present with TM perf 
C) Patients w/ congenital cholesteatoma tend to have well aerated mastoids 
D) Can present in anterior or posterior quadrants 
E) All of the above are true

Free Response Question:
Where are congenital cholesteatomas "classically" found? What do they look like on otoscope exam?

Quick Facts:

Round Window Anomalies
-Aplasia/hypoplasia associated w/ endemic cretinism and mandibulofacial dysostosis.
-Nonsyndromic cases are rare (less than 10 cases reported)
-Management unclear.
-Often associated w/ stapes ankylosis and diagnoses in retrospect after stapedectomy unsuccessful.
-Better to manage w/ amplification as surgical fenestration has led to poor results and carries risk of SNHL.

11/14/2013

11/14/2013

Answers:

With regards to embryology, Meckel's cartilage leads to formation of the --- whereas Reichert cartilage leads to formation of the---.
A) Stapes Footplate; Sphenomandibular ligament 
B) Long Process of Incus; Stapes Suprastructure
C) Body of Incus; Mandible  
D) Head of Malleus; Manubrium of Malleus

-Meckel cartilage (from 1st pharyngeal arch) = head of malleus / body of incus  mandible / sphenomandibular ligament.
-Reichert cartilage (2nd pharyngeal arch) = manubrium of malleus, long process of incus, stapes suprastructure and tympanic part of stapes footplate. Also, facial nerve,muscles of facial expression, stapedius, upper hyoid and stylohyoid ligament.

All of the muscles of facial expression are innervated on their deep side except for what three exceptions?

Buccinator, Levator Anguli and Mentalis are the three muscles not innervated on their deep side. A good mnemonic to remember this is BLAM.

MC Questions:
Which ossicle requires the longest period of development?
A) Incus 
B) Stapes 
C) Malleus 
D) They are all equal

Free Response Question:
What does a "high riding" bulb refer to?

Quick Facts:

Congenital Cholesteatomas
-Congenital cholesteatomas = middle ear cholesteatoma in presence of intact TM w/o hx of perf, OM, otorrhea or oto surgery.
-Several features distinguish congential from aquired coleasteatomas:
-Acquired often present in setting of existing ear pathology.
-Acquired mass is often symptomatic (otorrhea, otalgia, hearing loss)
-Acquired is found to be expanding in direct continuity w/TM perf or retraction pocket.
-Congenital not associated w/ oto pathology, often clinically silent and discovered incidentally.
-Congenital tend to have well aerated mastoids, unlikely acquired.
-Pathogenesis unclear
-"classically” in anterosuperior quadrant of mesotympanum (27-67%)
-Small pearls next to long process of malleus (minimal ossicular involvement/hearing loss)
-Treat w/ surgical removal.
-Recur in 30-55% of cases after surgery.