Otology and Neurotology: Middle Ear, Vertigo, and Facial Nerve Reasoning
Scope
Otology and neurotology questions test middle-ear mechanics, chronic otitis media and cholesteatoma, vestibular disorders, facial nerve localization, and implantable hearing devices. The board favors clinical reasoning over eponyms: connect a finding such as a perforation, air-bone gap, or nystagmus to a diagnosis and the next step.
Core rules
- A central perforation usually causes conductive loss proportional to area; an intact ossicular chain with a small perforation may show only a small gap. Posterior marginal or attic crusting suggests cholesteatoma, not simple chronic otitis media.
- Classify chronic otitis media as mucosal (inactive or active) or squamous. Cholesteatoma is surgical; repeated drops alone are inadequate.
- BPPV: brief positional vertigo, positive Dix-Hallpike for posterior canal, canalith repositioning first-line. Continuous vertigo with nausea and no hearing loss suggests vestibular neuritis.
- Definite Meniere disease: two or more spontaneous vertigo episodes lasting 20 minutes to 12 hours, audiometrically documented low- to mid-frequency sensorineural hearing loss, fluctuating aural symptoms, and no better explanation.
- Sudden sensorineural hearing loss is an emergency: audiogram promptly, MRI to exclude retrocochlear disease, high-dose corticosteroids.
- Otosclerosis: progressive conductive loss, normal tympanogram, Carhart notch at 2 kHz; stapes surgery or hearing aid.
Worked example
A 45-year-old reports recurrent 2-hour episodes of spinning vertigo, left aural fullness, tinnitus, and fluctuating hearing loss. Audiogram shows left low-frequency sensorineural loss with no air-bone gap; MRI is normal. This meets definite Meniere disease. Acute treatment is a short course of vestibular suppressant and antiemetic; maintenance includes salt restriction, intratympanic steroid for hearing preservation, and intratympanic gentamicin only for disabling vertigo. A tympanostomy tube is not indicated for Meniere disease.
Traps
Calling all positional vertigo BPPV without Dix-Hallpike; missing bilateral Meniere disease; treating cholesteatoma with antibiotics; ignoring asymmetric sensorineural loss; and misreading a Carhart notch as sensorineural loss.