1. Quinton Gopen, M.D. UCLA Medical Center Feb 27th, 2013
Inservice Review
Quinton Gopen, M.D.
UCLA Medical Center
Feb 27th, 2013

2. Left posterior Left superior Right lateral Right posterior
75 y.o. gentleman with vertigo when lays on right side. Counterclockwise nystagmus seen with right side down. Which semicircular canal is responsible?
Left posterior
Left superior
Right lateral
Right posterior

3. Answer:
Right posterior canal

4. Which type of nystagmus is most suggestive of central etiology ?
choices:
decreased with eye fixation
nystagmus changes with changing eye position
horizontal nystagmus
motion induced nystagmus
nystagmus which stops with fixed gaze

5. nystagmus changes with changing eye position
answer:
nystagmus changes with changing eye position

6. What structure is under efferent nerve control in the inner ear?
choices:
inner hair cell
stria vascularis
outer hair cells
spiral ligament
Deiter’s cells

7. answer:
outer hair cells

8. What form of words is used to test in SRT?
choices:
phoneme
spondee
balanced
recruited
tri-syllabic

9. answer:
spondee

10. Pt jammed Qtip into ear now with bloody discharge; has a perforation of the TM as well as hearing loss, vertigo, and nystagmus
choices:
Bedrest
Serial audiograms
Middle ear exploration
Lumbar Puncture
Meclizine

11. middle ear exploration
answer:
middle ear exploration

12. Most common autoimmune disease with middle ear involvement
choices:
SLE
polyarteritis nodosum
Wegerner's RA
Behcet's
sarcoidosis

13. Wegner's granulomatosis
answer:
Wegner's granulomatosis

14. Most common virus implicated in congenital hearing loss
choices:
CMV
Herpes
Toxoplasmosis
mumps
Varicella

15. discussion: congenital CMV infection accounts for a large amount of childhood deafness ~ k infants/year - roughly 1% of all newborns. All infants with congenital CMV infection shed the virus in high titers in bodily secretions. Definitive diagnosis can be confirmed by means of isolation of the virus from urine or saliva with PCR techniques within the first 2 weeks of life.
answer:
CMV

16. In malignant otitis externa, what is the best modality for following the infection ?
choices:
Gallium scan
CT scan
PET scan
technetium scan
MRI scan

17. discussion: technetium bone scan evaluates osteoblastic activity and is excellent for localizing the infection but will not normalize after infection has resolved. Gallium bone scan evaluates inflammation and follows the course of the malignant otitis externa
answer:
gallium scan

18. Young woman with bilateral moderate SNHL and diffuse thyroid enlargement; what is next step ?
choices:
perchlorate level
measure antithyroglobulin antibodies
renal UTZ
thyroid uptake scan
head CT

19. discussion: The woman has Pendred's syndrome, which is a defect in tyrosine iodination and presents as multinodular goiter at 8-14yrs old from failure of iodine organification - diagnosed by perchlorate levels (a positive perchlorate test is decreased perchlorate discharge). The treatment is exogenous thyroid hormone with thyroidectomy typically not required.
answer:
perchlorate level

20. Audiogram of pt with otosclerosis
Audiogram of pt with otosclerosis. H/o LT stapes now with very poor hearing in left ear (PTA 60dB, discrim 20%) Now with large air bone gap in right ear.
choices:
hearing aids
right stapedectomy
left stapedectomy
fluoride
left cochlear implant

21. answer:
hearing aids

22. What happens after stimulation of Jacobsen's nerve ?
choices:
increased lacrimation
decreased lacrimation
increased submandibular gland flow
decreased submandibular gland flow
increase parotid gland flow

23. increase parotid gland flow
discussion: Jacobsen's nerve, a branch of cranial nerve IX provides parasympathetic innervation via the otic ganglion and auriculotemporal nerve to the parotid gland.
answer:
increase parotid gland flow

24. Pt c/o pain in EAC with hand drawn picture showing area just inferior to TM - what is innervation?
choices:
Vagus
Trigeminal
Occipital
greater auricular
facial ?

25. discussion: Innervation of the inferior aspect of the EAC comes from the vagus nerve
see picture for innervation of the EAC quadrants
answer:
vagus

26. Pt with resection of mastoid facial neuroma how best reconstruct ?
choices:
XII-VII anastamosis
cable graft
VII-VII crossover
pedicled temporalis flap
facial sling

27. discussion: For facial nerve reconstruction, there is a definite order of preference in the method of repair. The first choice is always direct reapproximation of severed nerve ends, however due to tissue loss or in this case tumor resection this is not always possible. The second choice is a cable graft, with things like XII-VII and VII-VII coming after the cable graft in order of preference.
answer:
cable graft

28. Profuse bleeding during resection of a tumor involving the jugular bulb - what is blood supply ?
choices:
superior petrosal sinus
transverse sinus
inferior petrosal sinus
ascending pharyngeal
external carotid

29. inferior petrosal sinus
discussion: the jugular bulb becomes the internal jugular vein inferiorly; superiorly the sigmoid sinus and the inferior petrosal sinus culminate to form the jugular bulb, and profuse bleeding certainly can arise in this area. The superior petrosal sinus drains into the lateral extent of the sigmoid sinus. Of the two listed, the inferior petrosal sinus is the best choice.
answer:
inferior petrosal sinus

30. Maximum conductive loss comes from what ?
choices:
intact drum with ossicular discontinuity
total perforation
inferior perforation
superior perforation
middle ear effusion

31. intact drum with ossicular discontinuity
discussion: A maximum conductive hearing loss is obtained when there is ossicular discontinuity in the presence of an intact eardrum and is around 60dB
answer:
intact drum with ossicular discontinuity

32. Which nerve is responsible for gustatory sweating ?
choices:
Glossopharyngeal
Facial
Chordae
Lingual
Vidian nerve

33. discussion: the glossopharyngeal nerve innervates the parotid gland via the following pathway: inferior salvatory nucleus (medulla) - glossophayryngeal nerve (Jacobsen's nerve) - lesser superficial petrosal nerve - otic ganglion (now postganglionic fibers) - auriculotemporal nerve (CNV3) - partoid gland
After the parotid gland is cut out, the parasympathetic fibers aberently regenerate into the sweat glands which leads to Frey's syndrome, also known as gustatory sweating
answer:
glossopharyngeal

34. Tumor at fundus with intact hearing what would be best approach ?
choices:
Middle fossa
Suboccipital
Retrosigmoid
Translabyrinthine
Infracochlear

35. discussion: There are three main types of approach to CP angle tumors: translab, retrosigmoid and middle fossa. The translab can get out any size tumor but has the down side of destroying any residual hearing. The middle fossa and retrosigmoid approaches spare hearing but can only be used in certain instances: middle fossa is best for small tumors at the fundus (very far lateral just as nerve enters cochlea) whereas retrosigmoid (aka suboccipital) is best for tumor at the meatus (very far medially where the nerve exits the brainstem at the CP angle.
answer:
middle fossa

36. Which pt will do worst with a cochlear implant ?
choices:
postlingually deaf adult
postlingually deaf child
prelingually deaf child of short duration
sign language before implant
congenitally deaf

37. discussion: cochear implants (CI) depend on an intact cochlear nerve which can be stimulated, so the patients which do worse have the least viable cochlear nerve - this would be the congenitally deaf patient
answer:
congenitally deaf

38. Best hearing test for 8 month old ?
choices:
Behavioral
Play
Conventional
Visual reinforced
Infant

39. visual reinforced Discussion: conventional audiometry 3-4 years
behavioral audiometry 0-6months
visual reinforced months
play audiometry months
answer:
visual reinforced

40. CROS hearing aid is for ? choices: unilateral profound hearing loss
bilateral profound hearing loss
unilateral conductive hearing loss
chronic draining ear
poor manual dexterity

41. unilateral profound hearing loss
answer:
unilateral profound hearing loss

42. What structure is contained in the cochlear aqueduct ?
choices:
loose arachnoid tissue
endolymphatic duct
cochlear artery
singular nerve
subarcuate artery

43. loose arachnoid tissue
discussion: The structure contained inside the cochlear aqueduct is called the periotic duct and consists of loos connective tissue/loose arachnoid tissue
answer:
loose arachnoid tissue

44. While in surgery, the surgeon notes that he cog has been eroded by cholesteatoma, what is the most likely other structure to be affected ?
choices:
lateral semicircular canal
verticle facial nerve
labyrinthine facial nerve
tympanic facial nerve
Posterior semicircular canal

45. tympanic segment of facial nerve
discussion: The cog is a ridge of bone that extends inferiorly from the tegmen and separates the anterior epitympanum. The cog lies immediately superior to the cochleariform process. The tympanic segment of the facial nerve courses under the base of the cog.
answer:
tympanic segment of facial nerve

46. Site of ototoxicity of cisplatin ?
choices:
basal cochlea
apical cochlea
saccule
utricle
lateral semicircular canal

47. discussion: cisplatin causes selective loss of outer hair cells in basal turn of the cochlea; toxicity related to dose of individual cycle rather than total dose of therapy; elderly and young children more at risk
answer:
basal cochlea

48. What is the most common complication of cochlear implantation ?
choices:
flap necrosis
facial nerve stimulation
misplaced electrode
meningitis
encephalocele

49. discussion: Ear, Nose & Throat Journal, Dec, 1999, by Arvind Kumar, Richard Mugge, Marci Lipner
Flap-related problems continue to be the most common complications, although their rates have fallen from 5.44% in 1988 [1] to 2.79% in l995. [5] The incidence of compressed/misplaced electrodes has also declined, from 1.74 to 1.18%, as has the incidence of facial paresis, from 1.74 to 0.56%.
answer:
flap necrosis

50. Which cells are first damaged with noise exposure?
choices:
outer hair cells at apical turn
outer hair cells at basal turn
inner hair cells at apical turn
inner hair cells at base
Claudius cells

51. outer hair cells at basal turn
discussion: high frequencies are lost first in noise exposure, which corresponds to the basal portion of the cochlea - and outer hair cells are more sensitive than inner hair cells to noise exposure - so outer hair cells in the base
answer:
outer hair cells at basal turn

52. Cerebellopontine mass hypointense on T1 and hyperintense on T2
Also no gadolinium enhancement
choices:
cholesterol granuloma
lipoma
arachnoid cyst
Meningioma
acoustic neuroma

53. discussion: T1 images fat lights up whereas on T2 images water lights up; here we have a mass lighting up on T2 (like water) without enhancement when gadolinium is given. We can therefore rule out acoustic neuroma and meningioma which would enhance with gad and light up on T1 images. Arachnoid cyst is like a big water bag so this is a good possibility and is often found in the CP angle and doesn't enhance with contrast! Cholesterol granuloma is one of the few things that will be intense on both T1 and T2 images. Lipoma has T1 hyperintensity.
answer:
arachnoid cyst

54. Most common petrous apex lesion ?
choices:
Cholesteatoma
Mucocele
cholesterol granuloma
teratoma
malignant schwannoma

55. cholesterol granuloma
discussion: Cholesterol granuloma is the most common lesion of the petrous apex. It is approximately 10 times more common than cholesteatoma and 40 times more common than mucocele.
answer:
cholesterol granuloma

56. Child with otitis media and fluctuance in subQ tissue over mastoid with fever but no facial nerve paralysis
choices:
PET
PET and simple mastoidectomy
IV ABX
radical mastoidectomy
wide myringotomy

57. PET and simple mastoidectomy
discussion: Pt has a subperiosteal abscess (fluctuance) which must be drained via a simple mastoidectomy
answer:
PET and simple mastoidectomy

58. During a tympanoplasty mastoidectomy which medicaiton should anesthesia use to paralyze the patient ?
choices:
Atracuronium
Curare
Pancuronium
Rocuronium
Succinylcholine

59. discussion: the idea here is you must be able to monitor the facial nerve funtion throughout the case - so the shortest acting agent is the best – succinylcholine
answer:
succinylcholine