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ABOHNS Neurotology study materials
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ABOHNS Neurotology practice questions

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Question 1Neurotology

A 45-year-old woman reports brief episodes of vertigo triggered by rolling over in bed, lasting under one minute, with no hearing loss or tinnitus. Dix-Hallpike testing on the right reproduces torsional upbeating nystagmus after a brief latency. Which diagnosis is most likely?

  1. Meniere disease
  2. Superior semicircular canal dehiscence
  3. Vestibular neuritis
  4. Posterior canal benign paroxysmal positional vertigo Correct answer.

Explanation

Positional vertigo with a brief latency, short duration, and torsional upbeating nystagmus on Dix-Hallpike is the classic pattern of posterior canal canalithiasis. Meniere disease produces spontaneous episodes lasting 20 minutes to hours with fluctuating hearing loss, and vestibular neuritis produces prolonged spontaneous vertigo without positional triggering.

Question 2Neurotology

Which cranial nerve carries the afferent fibers of the acoustic (vestibulocochlear) component responsible for hearing?

  1. Trigeminal nerve
  2. Glossopharyngeal nerve
  3. Cochlear nerve Correct answer.
  4. Facial nerve

Explanation

The cochlear division of cranial nerve VIII carries auditory afferents from the spiral ganglion to the cochlear nuclei. The facial and trigeminal nerves are motor/sensory nerves of the face, and the glossopharyngeal nerve serves the oropharynx.

Question 3Neurotology

A patient has a left-sided peripheral facial palsy with inability to close the left eye and loss of taste over the anterior tongue. Which structure's involvement best explains the taste loss?

  1. Nerve to stapedius
  2. Greater petrosal nerve
  3. Posterior auricular nerve
  4. Chorda tympani Correct answer.

Explanation

The chorda tympani carries taste from the anterior two-thirds of the tongue and branches from the facial nerve within the middle ear. The greater petrosal nerve carries parasympathetic fibers to the lacrimal gland, and the nerve to stapedius supplies the stapedius muscle.

Question 4Neurotology

The vestibulo-ocular reflex stabilizes gaze during head movement. Which pairing of semicircular canal with its paired contralateral canal correctly describes the coplanar arrangement?

  1. Right horizontal with right posterior
  2. Left anterior with left horizontal
  3. Right posterior with right anterior
  4. Right anterior with left posterior Correct answer.

Explanation

The anterior canal on one side is coplanar with the posterior canal on the opposite side, and the two horizontal canals are coplanar with each other. This arrangement allows push-pull signaling during angular head rotation.

Question 5Neurotology

A 60-year-old man presents with sudden left-sided hearing loss and vertigo. Audiometry confirms a left moderate sensorineural hearing loss. Which finding on examination would most suggest a retrocochlear cause requiring MRI?

  1. Positive Rinne test bilaterally
  2. Normal binaural loudness summation
  3. Asymmetrically reduced acoustic reflex on the left Correct answer.
  4. Normal speech discrimination

Explanation

An absent or elevated acoustic reflex with asymmetrically poor speech discrimination suggests retrocochlear pathology such as vestibular schwannoma. A cochlear cause typically shows recruitment and preserved or proportionally reduced reflexes.

Question 6Neurotology

Which test assesses the integrity of the horizontal vestibulo-ocular reflex at high-frequency head rotation?

  1. Head impulse test Correct answer.
  2. Fistula test
  3. Dix-Hallpike maneuver
  4. Romberg test

Explanation

The head impulse (Halmagyi) test delivers rapid, small-amplitude head rotations and assesses the high-acceleration horizontal vestibulo-ocular reflex; a corrective saccade suggests canal paresis. Dix-Hallpike assesses positional nystagmus, and the Romberg test assesses proprioceptive balance.

Question 7Neurotology

A patient with intractable Meniere disease undergoes intratympanic gentamicin therapy. What is the primary intended mechanism of this treatment?

  1. Chemical ablation of vestibular hair cells Correct answer.
  2. Inhibition of the stapedial reflex
  3. Reduction of endolymphatic sac pressure
  4. Blockade of the cochlear aqueduct

Explanation

Intratympanic gentamicin is an aminoglycoside that is vestibulotoxic and is used to chemically ablate the vestibular end organs and reduce vertigo attacks. It does not act by decompressing the endolymphatic sac.

Question 8Neurotology

Which of the following best characterizes the hearing loss in superior semicircular canal dehiscence syndrome?

  1. Pseudoconductive low-frequency loss with intact acoustic reflexes Correct answer.
  2. Fluctuating sensorineural loss with aural fullness
  3. Unilateral high-frequency sensorineural loss with recruitment
  4. Profound mixed loss with absent otoacoustic emissions

Explanation

Superior canal dehiscence produces a third-window effect with low-frequency air-bone gap despite normal acoustic reflexes and often supranormal bone conduction (pseudoconductive loss). The inner ear is otherwise intact, so reflexes and otoacoustic emissions are preserved.

Question 9Neurotology

A 30-year-old woman has recurrent episodes of vertigo lasting hours with left aural fullness, tinnitus, and fluctuating hearing loss. Which finding on examination is most consistent with active Meniere disease?

  1. Absent response to caloric testing bilaterally
  2. Spontaneous horizontal nystagmus during an attack Correct answer.
  3. Torsional nystagmus on Dix-Hallpike
  4. Downbeating nystagmus with head shaking

Explanation

During an acute Meniere attack, a spontaneous horizontal or horizonto-rotatory nystagmus is commonly seen, often beating away from the affected ear. Positional torsional nystagmus suggests BPPV, and bilateral caloric areflexia is not typical of unilateral Meniere disease.

Question 10Neurotology

Which structure separates the middle ear from the mastoid air cells and is the site of the aditus ad antrum?

  1. Scutum
  2. Oval window
  3. Tegmen tympani
  4. Mastoid antrum Correct answer.

Explanation

The mastoid antrum is the largest mastoid air cell and communicates with the middle ear via the aditus ad antrum. The tegmen tympani forms the roof of the middle ear, and the oval window is the site of the stapes footplate.

Question 11Neurotology

A patient develops acute vestibular syndrome with continuous vertigo, nausea, and spontaneous horizontal nystagmus after a viral illness. The head impulse test shows a corrective saccade on the right, and there are no other neurologic deficits. What is the most likely diagnosis?

  1. Cerebellar infarction
  2. Vestibular neuritis Correct answer.
  3. Vertebrobasilar insufficiency
  4. Labyrinthitis

Explanation

Acute prolonged vertigo with an abnormal head impulse test and no hearing loss or central signs suggests vestibular neuritis. Labyrinthitis would include hearing loss, and central causes such as cerebellar infarction typically produce normal head impulse testing or other neurologic signs.

Question 12Neurotology

Which of the following is the most common site of vestibular schwannoma origin?

  1. Facial nerve
  2. Cochlear nerve
  3. Superior vestibular nerve
  4. Inferior vestibular nerve Correct answer.

Explanation

Most vestibular schwannomas arise from the vestibular division of cranial nerve VIII, most often the inferior vestibular nerve, near the internal auditory canal. The cochlear nerve and facial nerve are not the typical sites of origin.

Question 13Neurotology

A patient with a large vestibular schwannoma reports facial numbness. Which cranial nerve is most directly affected by tumor compression?

  1. Spinal accessory nerve
  2. Optic nerve
  3. Hypoglossal nerve
  4. Trigeminal nerve Correct answer.

Explanation

Large vestibular schwannomas in the cerebellopontine angle can compress the trigeminal nerve, causing facial numbness or altered sensation. The optic, hypoglossal, and spinal accessory nerves are not adjacent to the cerebellopontine angle in a way that would be affected first.

Question 14Neurotology

Which finding on videonystagmography best supports a peripheral vestibular lesion?

  1. Unidirectional horizontal nystagmus suppressed by visual fixation Correct answer.
  2. Gaze-evoked nystagmus in multiple directions
  3. Vertical nystagmus with fixation suppression
  4. Rebound nystagmus after eccentric gaze

Explanation

Peripheral vestibular nystagmus is typically unidirectional, horizontal with a torsional component, and is suppressed by visual fixation. Vertical or direction-changing nystagmus and failure of fixation suppression suggest central pathology.

Question 15Neurotology

Which test is used to evaluate endolymphatic hydrops by measuring the change in cochlear summating potential relative to the action potential?

  1. Tympanometry
  2. Electrocochleography Correct answer.
  3. Otoacoustic emissions
  4. Auditory brainstem response

Explanation

Electrocochleography records the summating potential and action potential; an elevated summating potential to action potential ratio supports endolymphatic hydrops. Auditory brainstem response evaluates retrocochlear pathways, and otoacoustic emissions reflect outer hair cell function.

Question 16Neurotology

A patient has positional vertigo. On Dix-Hallpike testing to the left, the examiner observes downbeating nystagmus that persists and does not fatigue. What is the most appropriate interpretation?

  1. Normal response
  2. Left posterior canal BPPV
  3. Right horizontal canal BPPV
  4. Central positional nystagmus Correct answer.

Explanation

Persistent, nonfatiguing downbeating positional nystagmus suggests a central cause rather than canalithiasis, which typically produces fatiguing torsional upbeating nystagmus. Downbeating nystagmus can localize to the cerebellar flocculus or lower brainstem.

Question 17Neurotology

Which structure is responsible for transducing angular acceleration of the head?

  1. Crista ampullaris Correct answer.
  2. Macula
  3. Utricle
  4. Saccule

Explanation

The cristae ampullares within the semicircular canals contain hair cells that detect angular acceleration as endolymph moves through the canals. The utricle and saccule contain maculae that detect linear acceleration and gravity.

Question 18Neurotology

A patient with a history of chronic middle ear disease develops vertigo, and a fistula test produces nystagmus. What is the most likely underlying mechanism?

  1. Endolymphatic hydrops
  2. Vestibular migraine
  3. Cerebellar degeneration
  4. Perilymph fistula Correct answer.

Explanation

A positive fistula test in the setting of chronic ear disease suggests a perilymph fistula, where pressure changes transmitted through the middle ear stimulate the vestibular end organs. Endolymphatic hydrops and vestibular migraine do not produce pressure-induced nystagmus.

Question 19Neurotology

Which canal is most commonly affected in benign paroxysmal positional vertigo?

  1. Anterior canal
  2. Horizontal canal
  3. Superior canal
  4. Posterior canal Correct answer.

Explanation

The posterior semicircular canal is the most common site of canalithiasis, accounting for the majority of BPPV cases. Horizontal and anterior canal variants occur but are less frequent.

Question 20Neurotology

Which treatment maneuver is most appropriate for posterior canal BPPV affecting the right ear?

  1. Epley canalith repositioning maneuver Correct answer.
  2. Valsalva maneuver
  3. Barbecue rotation maneuver
  4. Cawthorne-Cooksey exercises

Explanation

The Epley maneuver is a canalith repositioning procedure designed to move otoconia from the posterior canal back into the utricle. The barbecue rotation is used for horizontal canal BPPV, and Cawthorne-Cooksey exercises are general vestibular rehabilitation.

Question 21Neurotology

A patient with bilateral vestibular loss is at increased risk of which of the following?

  1. Facial nerve palsy
  2. Oscillopsia during head movement Correct answer.
  3. Conductive hearing loss
  4. Pulsatile tinnitus

Explanation

Bilateral vestibular loss impairs the vestibulo-ocular reflex, causing oscillopsia and blurred vision during head movement. It does not cause conductive hearing loss, pulsatile tinnitus, or facial palsy.

Question 22Neurotology

Which of the following best describes the pathophysiology of Meniere disease?

  1. Endolymphatic hydrops with elevated inner ear pressure Correct answer.
  2. Otoconia dislodgement into the semicircular canal
  3. Ischemia of the vestibulocochlear artery
  4. Demyelination of the vestibular nerve

Explanation

Meniere disease is characterized by endolymphatic hydrops, with increased volume and pressure of endolymph in the inner ear. Demyelination, otoconia dislodgement, and vascular ischemia describe other distinct entities.

Question 23Neurotology

A patient reports vertigo triggered by loud sounds and by pressure in the ear canal. Which diagnosis should be considered?

  1. Vestibular neuritis
  2. Vestibular migraine
  3. Superior semicircular canal dehiscence Correct answer.
  4. Posterior canal BPPV

Explanation

Sound- and pressure-induced vertigo (Tullio phenomenon) suggests a third-window lesion such as superior semicircular canal dehiscence. Vestibular migraine, BPPV, and vestibular neuritis do not produce sound- or pressure-triggered vertigo.

Question 24Neurotology

Which of the following findings on caloric testing is considered a significant asymmetry suggesting unilateral weakness?

  1. A 10% difference between ears
  2. Bilateral responses with a 10-second duration
  3. Equal responses with a 5-second latency
  4. A 30% difference between ears Correct answer.

Explanation

A unilateral weakness of 25% or more on binaural caloric testing is generally considered significant. Smaller differences such as 10% are within normal variability.

Question 25Neurotology

A patient has a unilateral sensorineural hearing loss with an ipsilateral absent acoustic reflex and poor speech discrimination. Which diagnosis is most likely?

  1. Presbycusis
  2. Vestibular schwannoma Correct answer.
  3. Noise-induced hearing loss
  4. Otosclerosis

Explanation

Unilateral sensorineural hearing loss with an absent acoustic reflex and poor speech discrimination is a classic retrocochlear pattern suggesting vestibular schwannoma. Otosclerosis causes conductive loss, and noise-induced loss and presbycusis are typically bilateral and cochlear.

Question 26Neurotology

A patient presents with episodic vertigo, left-sided hearing loss, and tinnitus. Audiometry shows a left sensorineural hearing loss. Which additional finding would be most consistent with a diagnosis of Meniere disease?

  1. Conductive hearing loss with a normal bone conduction curve
  2. Flat sensorineural hearing loss with poor speech discrimination
  3. High-frequency sensorineural hearing loss with a notch at 4 kHz
  4. Fluctuating hearing loss with a low-frequency sensorineural pattern Correct answer.

Explanation

Meniere disease is characterized by episodic vertigo, fluctuating sensorineural hearing loss, tinnitus, and aural fullness. The hearing loss often affects low frequencies early in the disease course and may fluctuate with attacks.

Question 27Neurotology

Which of the following is the most appropriate first-line treatment for a patient with benign paroxysmal positional vertigo affecting the posterior semicircular canal?

  1. Surgical occlusion of the posterior canal
  2. Epley canalith repositioning maneuver Correct answer.
  3. Vestibular suppressant medication
  4. Intratympanic gentamicin injection

Explanation

The Epley maneuver is a particle-repositioning procedure that moves otoconia from the posterior canal back into the utricle, and it is the first-line treatment for posterior canal BPPV. Medications and surgery are not first-line for uncomplicated BPPV.

Question 28Neurotology

A patient reports brief episodes of vertigo triggered by rolling over in bed or looking up. On examination, Dix-Hallpike testing reproduces the vertigo with a latency of a few seconds and fatigability. Which diagnosis is most likely?

  1. Meniere disease
  2. Benign paroxysmal positional vertigo Correct answer.
  3. Vestibular neuritis
  4. Vestibular schwannoma

Explanation

BPPV is characterized by brief, positional vertigo with latency and fatigability on Dix-Hallpike testing, caused by displaced otoconia in a semicircular canal. Vestibular neuritis and Meniere disease cause spontaneous, not strictly positional, vertigo.

Question 29Neurotology

A patient with a history of chronic middle ear disease presents with vertigo and nystagmus induced by pressure in the external auditory canal. Which structure is most likely involved?

  1. The posterior semicircular canal
  2. The cochlear duct
  3. The oval window Correct answer.
  4. The utricle

Explanation

A positive fistula test suggests an abnormal connection between the middle ear and the inner ear, often at the oval window or horizontal semicircular canal. Chronic middle ear disease can erode the bony labyrinth, and pressure changes then stimulate the vestibular system.

Question 30Neurotology

A patient with acute unilateral vestibular loss shows spontaneous horizontal nystagmus. Which direction of nystagmus is expected in the acute phase?

  1. Beating toward the affected ear
  2. Beating away from the affected ear Correct answer.
  3. Upbeating in all gaze positions
  4. Downbeating in all gaze positions

Explanation

In acute unilateral vestibular loss, the fast phase of nystagmus beats away from the affected side because the intact side drives the eyes away from the lesion. This follows the rule that the fast phase indicates the side of relative vestibular hyperactivity.

Question 31Neurotology

A patient with a large vestibular schwannoma reports facial numbness. Which cranial nerve is most directly affected by the tumor?

  1. Trigeminal nerve (CN V) Correct answer.
  2. Hypoglossal nerve (CN XII)
  3. Glossopharyngeal nerve (CN IX)
  4. Facial nerve (CN VII)

Explanation

Facial numbness indicates involvement of the trigeminal nerve (CN V), which lies adjacent to the cerebellopontine angle and can be compressed by a large vestibular schwannoma. The facial nerve (CN VII) would cause facial weakness, not numbness.

Question 32Neurotology

A patient with a history of recurrent vertigo is diagnosed with Meniere disease. Which pathophysiologic mechanism is most accepted as the underlying cause?

  1. Endolymphatic hydrops Correct answer.
  2. Vascular insufficiency of the labyrinth
  3. Demyelination of the vestibular nerve
  4. Vestibular hair cell degeneration

Explanation

Meniere disease is believed to result from endolymphatic hydrops, an increase in endolymph volume and pressure in the inner ear. This leads to the characteristic episodic vertigo and fluctuating hearing loss.

Question 33Neurotology

A patient reports vertigo and oscillopsia that clearly worsen in the dark and when standing on a soft, uneven surface. Which underlying deficit best explains this pattern?

  1. Impaired somatosensory and visual substitution for a bilateral vestibular deficit Correct answer.
  2. Loss of visual fixation suppression of the vestibulo-ocular reflex
  3. Unilateral semicircular canal hypofunction with normal contralateral function
  4. Central adaptation failure of the cerebellar flocculus

Explanation

When vestibular input is bilaterally lost, patients depend on vision and proprioception to maintain gaze and posture, so symptoms intensify when those cues are removed (darkness, compliant surfaces). This pattern reflects loss of bilateral vestibular function rather than a problem with fixation suppression or a single canal.

Question 34Neurotology

Which bedside finding is most characteristic of a peripheral (labyrinthine) cause of acute spontaneous vertigo?

  1. Vertical nystagmus that changes direction with gaze
  2. Nystagmus that reverses direction after head shaking
  3. Direction-changing horizontal nystagmus on lateral gaze
  4. Horizontal-rotatory nystagmus that is suppressed by visual fixation Correct answer.

Explanation

Peripheral vestibular nystagmus is typically mixed horizontal-torsional, unidirectional, and inhibited by visual fixation because the intact visual system can override the peripheral imbalance. Vertical or direction-changing gaze-evoked nystagmus points toward a central cause.

Question 35Otology

A 45-year-old man has a 6-month history of episodic vertigo lasting 20 minutes to several hours, fluctuating left-sided hearing loss, tinnitus, and aural fullness. Audiometry shows a low-frequency sensorineural loss. What is the most likely diagnosis?

  1. Vestibular migraine
  2. Meniere disease Correct answer.
  3. Vestibular schwannoma
  4. Benign paroxysmal positional vertigo

Explanation

The combination of episodic vertigo lasting minutes to hours with fluctuating sensorineural hearing loss, tinnitus, and aural fullness is the classic tetrad of Meniere disease, supported by a low-frequency sensorineural pattern on audiometry.

Question 36Otology

Which test is the gold standard for confirming the diagnosis of benign paroxysmal positional vertigo involving the posterior canal?

  1. Dix-Hallpike maneuver Correct answer.
  2. Head impulse test
  3. Electronystagmography with caloric testing
  4. Rotational chair testing

Explanation

The Dix-Hallpike maneuver provokes the characteristic upbeating-torsional nystagmus with latency and fatigability, confirming posterior canal canalithiasis. It is the diagnostic standard for this condition.

Question 37Otology

A 62-year-old woman with sudden unilateral sensorineural hearing loss presents within 48 hours of onset. Which intervention offers the best chance of hearing recovery?

  1. Oral vasodilators and bed rest
  2. Observation with repeat audiometry in 4 weeks
  3. High-dose oral corticosteroids started promptly Correct answer.
  4. Intratympanic gentamicin

Explanation

Idiopathic sudden sensorineural hearing loss is treated as an otologic emergency, and prompt high-dose systemic corticosteroids are the mainstay for improving recovery rates. Delay in treatment reduces the likelihood of recovery.

Question 38Otology

Which structure transmits the facial nerve from the internal auditory canal into the temporal bone?

  1. Fallopian canal Correct answer.
  2. Vestibular aqueduct
  3. Cochlear aqueduct
  4. Internal auditory meatus

Explanation

The facial nerve enters the Fallopian (facial) canal at the fundus of the internal auditory canal and travels through the temporal bone within it. This canal is the bony conduit for the facial nerve.

Question 39Otology

A patient reports a spinning sensation that begins when rolling over in bed and lasts about 15 seconds. Which physical finding is most consistent with posterior canal BPPV?

  1. Pendular nystagmus in primary gaze
  2. Downbeating nystagmus on head shake
  3. Upbeating torsional nystagmus on Dix-Hallpike Correct answer.
  4. Horizontal nystagmus that changes direction with gaze

Explanation

Posterior canal canalithiasis produces a characteristic upbeating and torsional nystagmus provoked by the Dix-Hallpike maneuver, with latency and fatigability. This pattern reflects excitation of the posterior canal ampulla.

Question 40Otology

Which of the following best describes the mechanism of the canalith repositioning (Epley) maneuver?

  1. It moves displaced otoconia from the canal back into the utricle Correct answer.
  2. It reduces endolymphatic pressure
  3. It ablates the posterior semicircular canal
  4. It strengthens central vestibular compensation

Explanation

The Epley maneuver uses sequential head and body positions to guide free-floating otoconia out of the posterior canal and back into the utricle, relieving the positional excitation. It does not destroy canal function.

Question 41Otology

A tuning fork test shows that air conduction is better than bone conduction in both ears, with bone conduction equal in both ears. Which interpretation is correct?

  1. Normal hearing or symmetric sensorineural loss Correct answer.
  2. Left-sided sensorineural hearing loss
  3. Bilateral conductive hearing loss
  4. Right-sided conductive hearing loss

Explanation

Air conduction greater than bone conduction (positive Rinne) in both ears indicates no conductive component. Symmetric bone conduction with equal air-bone gaps of zero is consistent with normal hearing or symmetric sensorineural loss, which cannot be distinguished by tuning fork alone.

Question 42Otology

Which cranial nerve is most commonly affected by a vestibular schwannoma as it enlarges beyond the internal auditory canal?

  1. Trigeminal nerve Correct answer.
  2. Hypoglossal nerve
  3. Glossopharyngeal nerve
  4. Facial nerve

Explanation

As vestibular schwannomas enlarge, they typically compress the trigeminal nerve at the cerebellopontine angle, causing facial numbness or altered sensation. The facial nerve is more resistant and usually affected later.

Question 43Otology

A 55-year-old man has severe vertigo, nausea, and spontaneous horizontal-torsional nystagmus with a positive head impulse test on the right. He has no hearing loss or focal neurologic deficits. What is the most likely diagnosis?

  1. Cerebellar infarction
  2. Meniere disease
  3. Vestibular neuritis Correct answer.
  4. Labyrinthitis

Explanation

Acute prolonged vertigo with a positive head impulse test and no hearing loss points to vestibular neuritis, an inflammation of the vestibular nerve. The absence of auditory symptoms distinguishes it from labyrinthitis.

Question 44Otology

Which feature best distinguishes vestibular migraine from Meniere disease?

  1. Migrainous headache with photophobia during attacks Correct answer.
  2. Fluctuating sensorineural hearing loss
  3. Positive head impulse test
  4. Presence of positional vertigo

Explanation

Vestibular migraine attacks are typically accompanied by migrainous features such as headache, photophobia, or phonophobia, and hearing loss is not a defining feature. Meniere disease is characterized by fluctuating sensorineural hearing loss and aural fullness.

Question 45Otology

A patient with chronic suppurative otitis media develops vertigo and a positive fistula test. Which complication is most likely?

  1. Sigmoid sinus thrombosis
  2. Intracranial abscess
  3. Facial nerve paralysis
  4. Labyrinthine fistula Correct answer.

Explanation

A positive fistula test with vertigo in the setting of chronic ear disease suggests erosion of the otic capsule, most often at the lateral semicircular canal, creating a labyrinthine fistula. Pressure changes then provoke nystagmus and vertigo.

Question 46Otology

Which audiometric configuration is most characteristic of early Meniere disease?

  1. High-frequency sensorineural hearing loss
  2. Low-frequency sensorineural hearing loss Correct answer.
  3. Flat conductive hearing loss
  4. Maximal conductive loss at 2000 Hz

Explanation

Early Meniere disease typically produces a fluctuating low-frequency sensorineural hearing loss that later becomes broader. This pattern reflects the effect of endolymphatic hydrops on apical cochlear function.

Question 47Otology

A 70-year-old woman has severe unremitting vertigo from Meniere disease that has failed dietary and medical therapy, with useful hearing in the affected ear. Which surgical option best preserves hearing while reducing vertigo?

  1. Labyrinthectomy
  2. Translabyrinthine resection
  3. Vestibular nerve section with hearing sacrifice
  4. Endolymphatic sac decompression Correct answer.

Explanation

Endolymphatic sac decompression aims to reduce endolymphatic pressure and vertigo attacks while preserving residual hearing, making it suitable when hearing is worth saving. Ablative procedures sacrifice hearing.

Question 48Otology

A patient develops acute facial palsy with vesicles in the external auditory canal and auricular pain. Which diagnosis is most likely?

  1. Vestibular schwannoma
  2. Acute otitis externa
  3. Ramsay Hunt syndrome Correct answer.
  4. Bell palsy

Explanation

Facial palsy with herpetic vesicles in the ear canal or auricle and otalgia is characteristic of Ramsay Hunt syndrome, caused by varicella-zoster virus reactivation in the geniculate ganglion. Antiviral therapy plus corticosteroids is the standard treatment.

Question 49Otology

Which finding on electronystagmography most strongly suggests a central rather than peripheral vestibular lesion?

  1. Unilateral canal paresis on caloric testing
  2. Fatigability of positional nystagmus
  3. Saccadic pursuit eye movements Correct answer.
  4. Latency of nystagmus after caloric stimulation

Explanation

Saccadic (broken) pursuit eye movements indicate dysfunction of central pursuit pathways and point to a central lesion. Peripheral lesions typically produce normal pursuit with abnormalities limited to vestibular responses.

Question 50Otology

A patient reports hearing loss and tinnitus, and MRI reveals a mass in the cerebellopontine angle extending into the internal auditory canal. Which tumor is most likely?

  1. Vestibular schwannoma Correct answer.
  2. Epidermoid cyst
  3. Cholesteatoma
  4. Meningioma

Explanation

A mass centered on the internal auditory canal with sensorineural hearing loss and tinnitus is most commonly a vestibular schwannoma arising from the vestibular division of the eighth nerve. Meningiomas and epidermoids can occur at the cerebellopontine angle but are less common and usually have different imaging features.