Chronic Suppurative Otitis Media and Cholesteatoma MCQs

ENT · 74 free questions with answers & explanations.

1. A 28-year-old man presents with right-sided foul-smelling ear discharge for 3 years. Examination shows a white, pearly mass in the posterior-superior quadrant of the tympanic membrane with marginal perforation. CT temporal bone demonstrates erosion of the scutum. The most appropriate management is:
2. In chronic suppurative otitis media, the type of perforation that is considered 'safe' (tubotympanic) is characteristically:
3. A child is found to have a cholesteatoma at birth in the middle ear with an intact tympanic membrane. The most likely pathogenesis of this cholesteatoma is:
4. The most common intracranial complication of CSOM with cholesteatoma is:
5. A patient with CSOM develops sudden onset facial palsy, high-grade fever with rigors, and a spiking temperature chart. He is drowsy but rousable. The MOST likely complication is:
6. A patient with CSOM develops sudden complete ipsilateral sensorineural hearing loss, severe vertigo, and nystagmus while being treated for an acute exacerbation. CT shows erosion of the horizontal semicircular canal. The most likely complication is:
7. The matrix of cholesteatoma consists of which type of epithelium, and the perimatrix (lamina propria) contains which characteristic enzymatic activity responsible for bone erosion?
8. A 9-year-old child with Down syndrome presents with bilateral conductive hearing loss and bilateral otorrhoea for 2 years. Tympanometry shows bilateral Type B curves. The underlying mechanism favouring chronic otitis media in this child is:
9. The most common ossicle to be eroded by cholesteatoma is the:
10. A 40-year-old patient who had a canal wall down (modified radical) mastoidectomy 5 years ago presents with a self-cleaning, dry, odourless cavity. Which term correctly describes this ideal postoperative outcome?
11. A 35-year-old patient with chronic ear discharge undergoes high-resolution CT mastoid, which reveals an erosion of the scutum (spur of Henle), soft tissue in Prussak's space, and lateral semicircular canal dehiscence. Which mechanism best explains the bone erosion by cholesteatoma?
12. During canal wall down mastoidectomy for cholesteatoma, the surgeon identifies an exposed sigmoid sinus. Which intraoperative complication has just been recognized, and what is the immediate management?
13. In the classification of cholesteatoma by site of origin, which of the following is the LEAST common type?
14. A patient with CSOM-unsafe develops extradural abscess and meningism. After CT head confirming the extradural collection and active cholesteatoma, what is the correct order of management?
15. Which of the following features on high-resolution CT (HRCT) mastoid is MOST specific for erosive cholesteatoma versus mucosal CSOM?
16. A 28-year-old presents with a pearly white mass visible through an attic perforation. Biopsy shows stratified squamous epithelium with a fibrous matrix. The matrix of cholesteatoma is characterised by which cell type responsible for bone erosion?
17. In the staging system for cholesteatoma (EAONO/JOS 2017 consensus), Stage III disease corresponds to:
18. During canal wall down mastoidectomy for cholesteatoma, the surgeon creates a 'meatoplasty.' The primary purpose of this step is to:
19. A patient with active COM with cholesteatoma develops acute onset vertigo, nausea, and a positive fistula test. CT shows dehiscence of the lateral semicircular canal. The MOST appropriate immediate management is:
20. In tubotympanic type CSOM (safe ear), the bacteria most commonly isolated in pure cultures from the chronic discharge is:
21. Which of the following is the MOST common intracranial complication of CSOM with cholesteatoma, and what is the pathogenetic mechanism by which cholesteatoma erodes bone?
22. During tympanomastoid surgery for attico-antral CSOM, the surgeon identifies a 'danger area' at risk of facial nerve injury in the mastoid. Which of the following best describes this area?
23. A 35-year-old presents with painless otorrhea and a posterior superior marginal perforation. CT temporal bone shows erosion of the scutum (lateral attic wall) and the ossicular chain is destroyed at the incus body. The ideal surgical approach would be:
24. A CT of temporal bone in a patient with CSOM shows a 'crescent sign' — a peripheral rim of hypodensity around a soft tissue mass filling the epitympanum. This finding is most consistent with:
25. A 28-year-old with CSOM atticoantral type has bony erosion of the lateral wall of the epitympanum seen on HRCT temporal bone. This erosion occurs because the cholesteatoma matrix expands primarily via which mechanism involving osteoclast activation?
26. In classifying the origin of acquired cholesteatoma, Ruedi proposed which mechanism as the primary cause of the most common pars flaccida cholesteatoma?
27. A patient with CSOM tubotympanic type is planned for tympanoplasty. Which graft material has the advantage of providing a framework for epithelialization but is associated with the highest risk of primary graft failure due to inadequate vascularization in an underlay technique?
28. The first ossicle to show erosion in cholesteatoma is the long process of the incus. The ossicular chain reconstruction technique using the patient's own eroded incus reshaped as an interposition graft is called:
29. A patient with CSOM presents with post-auricular fistula with pulsatile discharge and brownish granulation tissue. CT temporal bone shows destruction of the posterosuperior wall of the external auditory canal. The most likely complication is:
30. A 30-year-old woman presents with long-standing ear discharge and a perforation in the pars tensa. Audiometry shows a 40 dB air-bone gap with a type B tympanogram. Intraoperatively, a pearly white mass is seen in the middle ear. What is the MOST likely diagnosis?
31. Which enzyme class, secreted by cholesteatoma matrix, is primarily responsible for the bone erosion seen in cholesteatoma?
32. In a canal wall down (modified radical) mastoidectomy, what is the critical step that determines the adequacy of the meatoplasty?
33. A 12-year-old boy presents with a white pearly mass behind an intact tympanic membrane discovered incidentally during routine examination. There is no otorrhoea and audiometry shows mild conductive hearing loss. What is the embryological basis of this condition?
34. A patient with CSOM-unsafe type develops sudden facial palsy and vertigo. CT temporal bone shows erosion of the tegmen and lateral semicircular canal. The MOST appropriate management is:
35. A 35-year-old patient with known cholesteatoma develops sudden-onset profuse clear watery discharge from the ear after straining. The discharge tests positive for beta-2 transferrin. Which complication has most likely occurred?
36. The most widely accepted theory of acquired cholesteatoma pathogenesis is the retraction pocket theory. The negative middle ear pressure responsible for pars flaccida retraction is primarily caused by:
37. A patient with unsafe CSOM develops spiking 'picket-fence' fever with rigors, postauricular oedema (Griesinger's sign), and headache. Intraoperatively, the sigmoid sinus is found thrombosed. After mastoidectomy and removal of diseased bone, the most appropriate management of the sigmoid sinus thrombosis is:
38. Cholesteatoma produces bone erosion through enzymatic and cellular mechanisms. Which combination best describes the primary mediators?
39. After canal wall-down mastoidectomy for cholesteatoma, a patient presents with a recurrently discharging, moist mastoid cavity 8 months postoperatively. The most common surgical cause of this 'problem cavity' is:
40. A 35-year-old man with left-sided CSOM (atticoantral type) presents with sudden onset severe otalgia, high fever, and retroauricular swelling with displacement of the auricle forward and downward. CT shows a sub-periosteal abscess over the mastoid. What is the MOST appropriate initial surgical management?
41. Regarding the pathogenesis of acquired cholesteatoma via the invagination theory, which of the following best describes the initial step?
42. A CT temporal bone in a patient with cholesteatoma shows erosion of the lateral wall of the epitympanum (scutum). This finding is pathognomonic of which type of cholesteatoma, and which route of spread is most likely?
43. In modified radical mastoidectomy (Bondy operation), which structure is preserved that distinguishes it from a radical mastoidectomy?
44. A patient with CSOM and cholesteatoma develops sudden complete sensorineural hearing loss on the same side. Which mechanism is most likely responsible?
45. A 40-year-old male with unsafe CSOM has a cholesteatoma that has eroded the tegmen and caused otitic meningitis. After IV antibiotics and neurosurgical consultation, the appropriate ENT surgical timing is:
46. Prussak's space is the most common origin of acquired (primary) attic cholesteatoma. Which boundaries define Prussak's space?
47. A 40-year-old patient with atticoantral CSOM undergoes high-resolution CT mastoid. The CT shows erosion of the scutum (outer attic wall) with opacification of the epitympanum and middle ear. The pathological process most responsible for bony erosion in this condition is:
48. The 'blue drum' sign (blue or brownish discolouration of the tympanic membrane) in the posterior superior quadrant is characteristic of:
49. The most common complication of CSOM that can present as a soft, fluctuant, tender swelling in the posterior ear canal wall ('sagging posterior meatal wall') is:
50. A 30-year-old presents with persistent foul-smelling ear discharge and conductive hearing loss. Otoscopy shows a pearly white mass in the posterosuperior quadrant with an attic retraction pocket. CT temporal bone reveals a soft-tissue mass eroding the scutum and lateral attic wall with erosion of the long process of incus. Which microscopic layer of cholesteatoma matrix is directly responsible for bone erosion?
51. In a 'canal wall up' (combined approach tympanoplasty) technique for cholesteatoma, what is the primary advantage over the 'canal wall down' technique?
52. A 30-year-old patient with longstanding CSOM (attico-antral type) develops sudden onset facial nerve palsy, vertigo, and purulent otorrhoea. CT temporal bone shows erosion of the lateral semicircular canal and tegmen tympani. Which complication of cholesteatoma is most likely, and what is the urgent surgical priority?
53. In acquired cholesteatoma formation, the most widely accepted pathogenetic mechanism (immigration/invagination theory) involves which pathological process?
54. A patient with atticoantral CSOM has a cholesteatoma eroding the tegmen tympani. The structure immediately superior to the tegmen tympani that is at risk of involvement is:
55. The enzyme primarily responsible for the destructive osteolytic property of cholesteatoma is:
56. A second-look tympanoplasty ('second-stage surgery') after a combined approach tympanoplasty for cholesteatoma is typically scheduled after how many months?
57. A patient with attic cholesteatoma undergoes surgery. The surgeon observes that the matrix of the cholesteatoma has extended medially to erode the bony labyrinth, creating a fistula of the horizontal semicircular canal. Clinically, this would manifest as a positive:
58. In a patient with unsafe CSOM (cholesteatoma), intracranial complication develops with fever, severe headache, neck rigidity, and papilledema. CT shows sigmoid sinus thrombosis. The organism most commonly implicated in otogenic sigmoid sinus thrombosis is:
59. A congenital cholesteatoma is found in a 3-year-old child as a white pearly mass behind an intact normal tympanic membrane, anterior to the malleus. The most widely accepted theory for the origin of congenital cholesteatoma is:
60. A patient with CSOM-safe (tubotympanic) type develops sudden onset severe vertigo, vomiting, and profound sensorineural hearing loss on the affected side. On examination, there is a fistula sign (positive Hennebert sign). Which complication has most likely occurred?
61. In cholesteatoma, the keratin matrix is mainly composed of which cell type, and what property makes it locally destructive?
62. A patient with atticoantral (unsafe) CSOM is found to have erosion of the tegmen tympani on HRCT and presents with meningismus and photophobia. Lumbar puncture shows turbid CSF with polymorphonuclear pleocytosis. What is the MOST likely route of spread?
63. During surgery for cholesteatoma, the facial nerve is identified in its tympanic (horizontal) segment. The landmark used to identify the tympanic segment of the facial nerve in the middle ear is:
64. A secondary acquired cholesteatoma is believed to arise via which mechanism?
65. A 38-year-old patient with chronic ear discharge undergoes surgery. Intraoperatively, the surgeon finds a pearly white mass eroding the posterosuperior canal wall, involving the attic and destroying the long process of the incus. The mass stains positive for CK5/6 and p63 on immunohistochemistry. The underlying pathogenesis most consistent with this is:
66. In a patient with CSOM-safe (tubotympanic) disease, the tympanic membrane perforation is characteristically:
67. A child with CSOM and cholesteatoma develops Bezold's abscess. This complication arises from erosion of the:
68. In a patient with cholesteatoma, CT temporal bone (non-contrast) with reformats is the investigation of choice over MRI for initial evaluation. However, MRI DWI (diffusion-weighted imaging) is increasingly used because it:
69. A 25-year-old presents with painless ear discharge, central perforation, and conductive hearing loss. Audiometry reveals a 30 dB conductive hearing loss. The ossicle most commonly eroded in CSOM with mucosal disease (tubotympanic type) is:
70. A cholesteatoma is defined histologically as:
71. A 40-year-old with a known right-sided atticoantral CSOM develops sudden onset right facial palsy (House-Brackmann Grade IV) and purulent ear discharge. The most appropriate immediate management is:
72. The 'acquired' pathogenesis theory of cholesteatoma most widely accepted today involves:
73. Which investigation of choice confirms the diagnosis and extent of cholesteatoma when endoscopic findings are equivocal or to plan surgery?
74. Attic perforation with a foul-smelling discharge, scanty in quantity, and presence of a whitish flaky material in the attic on otoscopy is MOST characteristic of: