Chapter Reviews & Inservice Quiz

1. Chapter Reviews&Inservice Quiz Quinton Gopen, M.D. UCLA Medical Center Nov 17th, 2010

2. Coronal CT scan (normal) 1 2 3

3. Coronal CT (normal) 4

4. CT scan quiz 5

5. Axial MR (normal) 8 6 7

6. 9 11 12 10

17. Board Review Quinton Gopen, MD

18. 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

19. answer: nystagmus changes with changing eye position

20. 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

21. answer: outer hair cells

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

23. answer: spondee

24. 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

25. answer: middle ear exploration

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

27. answer: Wegner's granulomatosis

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

29. 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

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

31. 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

32. 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

33. 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

34. 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

35. answer: hearing aids

36. 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

37. 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

38. 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 ?

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

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

41. 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

42. 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

43. 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

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

45. 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

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

47. 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

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

49. 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

50. 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