Inservice Review

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

2. 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. 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. answer: middle ear exploration

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

13. 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 ~ 30-40k 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. 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. 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. 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. 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. Discussion: conventional audiometry 3-4 years behavioral audiometry 0-6months visual reinforced 7-36months play audiometry 36-60months 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. 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. 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. 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