SHORT ANSWERS - 1) Referred otalgia 2)Acute otalgia 3)Causes of pain in the ear 4) Bone anchored hearing aids 5) Vestibular Schwanoma — clinical features 6) Hitselberger’s sign 7) Glomus tympanicum 8)Crocodile tears 9) Exostosis in external auditory canal 10) Lermoyez syndrome 11) Treatment (acute attack) of Meniere’s disease 12)What is otosclerosis? What are its signs and symptoms? 13)Paracusis Willisi 15) Schwartz’s sign 16)Carhart’s notch 17)Management of otosclerosis 18) Mention extracranial complications of CSOM 19) List intracranial complications of CSOM 20) Griensinger's sign 21) Furunculosis of ear. 22) Bezold's abscess 23) Tympanic membrane 24) Test for malingering 25) Collaural fistula 26) Nerve supply of external ear. 27) Radilogical views for Ear. 28) Mac Evans triangle. 29) Fistula test Answer the following questions from ent dhingra as per RGUHS

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I've exhausted my DB query budget. I now have sufficient foundational data from the library plus my comprehensive ENT knowledge base from Dhingra. Let me compile all 29 short answers now.Here are all the short answers as per Dhingra's Diseases of Ear, Nose and Throat (RGUHS pattern):

ENT SHORT ANSWERS - Dhingra (RGUHS)

1. Referred Otalgia

Pain felt in the ear due to disease in a remote site, transmitted via shared nerve pathways. The sensory supply of the ear involves CN V, VII, IX, X, and cervical nerves C2-C3 - disease in areas supplied by these nerves can refer pain to the ear.

Common causes by nerve:

CN V (Trigeminal): Dental caries, impacted molar, TMJ arthritis, oral ulcers
CN IX (Glossopharyngeal): Tonsillitis, tonsillar abscess, nasopharyngeal carcinoma
CN X (Vagus): Laryngeal/hypopharyngeal carcinoma, thyroid disease
CN VII (Facial): Geniculate neuralgia (Ramsay Hunt syndrome)
C2-C3 (Cervical): Cervical spondylosis, cervical lymphadenopathy

Referred otalgia is more common in adults (>50% of adult otalgia). Isolated unilateral otalgia in adults may be the only presenting sign of aerodigestive tract malignancy - must be excluded.

2. Acute Otalgia

Acute pain in the ear of sudden onset. It is the most common presenting complaint in ear disease.

Causes:

External ear: Furunculosis (most common cause of severe acute otalgia), otitis externa, perichondritis, herpes zoster (Ramsay Hunt)
Middle ear: Acute otitis media (AOM), acute mastoiditis, barotrauma (aerotitis)
Eustachian tube: Eustachian tube dysfunction

Features: In AOM, pain is severe, throbbing, and relieved when the drum perforates (with discharge). In furunculosis, pain is aggravated by tragal pressure and jaw movement.

3. Causes of Pain in the Ear

Primary (otogenic) causes:

External ear: furunculosis, otitis externa, perichondritis, wax impaction (rarely), foreign body, herpes zoster oticus, carcinoma EAC
Middle ear: AOM, acute mastoiditis, barotrauma, bullous myringitis
Eustachian tube dysfunction

Secondary (referred) causes (no primary ear pathology):

CN V: dental - impacted molar, TMJ syndrome, oral ulcer
CN IX: tonsillitis, peritonsillar abscess, glossopharyngeal neuralgia
CN X: carcinoma larynx/hypopharynx, esophageal disease
CN VII: Ramsay Hunt syndrome, Bell's palsy (prodrome)
Cervical: cervical spondylosis, styloid process elongation (Eagle's syndrome)

4. Bone Anchored Hearing Aid (BAHA)

BAHA is an osseointegrated implantable hearing device that bypasses the outer and middle ear and directly stimulates the cochlea via bone conduction through a titanium fixture implanted in the skull.

Components:

Titanium implant (fixture) - placed in mastoid area
Abutment (percutaneous coupling)
Externally worn sound processor

Principle: Sound vibrations transmitted directly through bone to the cochlea, bypassing the external and middle ear.

Indications:

Conductive hearing loss when conventional aids not possible (chronic ear discharge, atresia)
Mixed hearing loss
Unilateral profound SNHL (CROS-BAHA)
Congenital aural atresia

Advantages: Bypasses diseased ear canal/middle ear; no occlusion effect; better sound quality in conductive HL.

Contraindication: Bone conduction threshold >45 dB (insufficient cochlear reserve).

5. Vestibular Schwannoma - Clinical Features

Also called acoustic neuroma; arises from Schwann cells of the vestibular division of CN VIII in the internal auditory meatus.

Symptoms (triad):

Unilateral SNHL - progressive, insidious; most common presentation (~95%)
Tinnitus - unilateral, high-frequency
Vertigo/imbalance - usually mild, gradual (as opposed to acute attacks)

Other features:

Hitselberger's sign (see below)
Facial numbness (CN V involvement as tumor enlarges)
Facial weakness (CN VII - late sign)
Cerebellar signs: ataxia, dysdiadochokinesia (with large tumors)
Headache, papilledema, features of raised ICP (very large tumors)

Audiological findings:

SNHL with poor speech discrimination (out of proportion to pure tone loss)
Absent stapedial reflexes / reflex decay
Abnormal ABR (increased interwave latency I-III, III-V)
Absent caloric response on affected side

Diagnosis: MRI with gadolinium (gold standard) - shows enhancing lesion in IAM/CPA.

6. Hitselberger's Sign

Hypoesthesia (reduced sensation) of the posterosuperior wall of the external auditory canal on the affected side in acoustic neuroma (vestibular schwannoma).

Basis: The skin of the posterior EAC is supplied by the auricular branch of the vagus nerve (Arnold's nerve) and also receives a contribution from the facial nerve. Compression of the facial nerve at the level of the IAM by the growing schwannoma causes this sensory loss.

It is an early sign of acoustic neuroma, described by Hitselberger and House (1966).

7. Glomus Tympanicum

A benign, highly vascular paraganglioma (chemodectoma) arising from the glomus bodies (paraganglia) situated along the Jacobson's nerve (tympanic branch of CN IX) on the promontory of the middle ear.

Clinical features:

Pulsatile tinnitus (most common symptom) - synchronous with pulse
Conductive hearing loss
On otoscopy: reddish-blue vascular mass behind intact tympanic membrane on the promontory
Brown's sign (Rising Sun sign): Blanching of the mass on pneumatic otoscopy (applying positive pressure)
Aquino's sign: Pulsation of the mass visible through tympanic membrane

Investigations:

CT temporal bone (axial) - shows soft tissue mass on promontory
MRI - "salt and pepper" appearance
Angiography for large lesions

Treatment:

Small lesions: Surgical excision via tympanotomy
Large lesions: Pre-op embolization + surgery
Radiotherapy for inoperable cases

Diferentiate from Glomus Jugulare: Glomus tympanicum is confined to middle ear; jugulare arises from jugular bulb and is more aggressive.

8. Crocodile Tears (Bogorad's Syndrome / Gustatory Lacrimation)

Abnormal reflex lacrimation (tearing from the eye) that occurs during eating or even at the sight/smell of food, instead of normal salivation.

Pathophysiology: Due to misdirection (aberrant regeneration) of regenerating autonomic nerve fibers after a facial nerve lesion (Bell's palsy, surgical trauma, herpes zoster). Fibers originally destined for the submandibular/sublingual salivary glands are redirected to the lacrimal gland. Hence eating stimulates lacrimation instead of salivation.

Cause: It is a late complication of Bell's palsy or any proximal facial nerve injury. The nerve lesion must be proximal to the geniculate ganglion (the greater petrosal nerve, which carries secretomotor fibers to the lacrimal gland, branches from the geniculate ganglion).

Treatment: Injection of botulinum toxin into the lacrimal gland (most effective).

9. Exostosis of External Auditory Canal

A benign, sessile bony outgrowth from the periosteum of the bony external auditory canal.

Characteristics:

Broad-based, smooth, rounded
Usually bilateral and multiple
Located in the deep bony meatus, medial to the isthmus
Covered by thin skin

Etiology: Chronic cold water exposure (swimmers, surfers) - called "surfer's ear." Cold water stimulates periosteal bone proliferation.

Symptoms:

May be asymptomatic (incidental finding)
Conductive hearing loss (when large enough to obstruct)
Recurrent otitis externa (due to retained water/debris)
Sense of ear blockage

Differential from Osteoma: Osteoma is unilateral, pedunculated, single, more lateral, and not related to cold water.

Treatment: Conservative if small/asymptomatic. Surgical canalplasty (drilling out the exostoses via endaural approach) when symptomatic.

10. Lermoyez Syndrome

A variant of Meniere's disease, first described by Lermoyez in 1921.

Classical description: "Hearing improves with vertigo" - i.e., the patient experiences increasing deafness and tinnitus, which is then followed by a vertiginous attack; after the attack, hearing paradoxically improves and tinnitus diminishes.

Contrast with Meniere's disease: In classical Meniere's, hearing worsens during/after the vertiginous attack. In Lermoyez, hearing improves after the attack.

Pathophysiology: The vasospasm theory - labyrinthine vasospasm causes deafness; the spasm breaks during the vertiginous attack, causing restoration of circulation and temporary improvement in hearing.

Clinical significance: Important variant to recognize; treated similarly to Meniere's disease.

11. Treatment of Acute Attack of Meniere's Disease

The goal during an acute attack is to relieve the severe vertigo, nausea, and vomiting.

Medical (Symptomatic):

Bed rest in a quiet, dark room
Vestibular sedatives (vestibular suppressants):
- Prochlorperazine (Stemetil) IM/rectal - drug of choice for acute attack
- Promethazine (Phenergan) IM
- Diazepam IV/IM (also reduces anxiety)
Antiemetics: Domperidone, Ondansetron
Antihistamines: Cinnarizine, Meclizine (less effective in acute severe attack)

Maintenance (Long-term prophylaxis - separate from acute treatment):

Low sodium diet (<1500 mg/day), avoid caffeine/alcohol/tobacco
Betahistine (vasodilator)
Diuretics (hydrochlorothiazide + triamterene)

Surgical (intractable cases - not for acute attack):

Intratympanic gentamicin/steroids
Endolymphatic sac decompression/shunt
Labyrinthectomy, vestibular neurectomy

12. Otosclerosis - Definition, Signs and Symptoms

Definition: Otosclerosis is a disease of the bony labyrinthine capsule (otic capsule) in which normal enchondral bone is replaced by irregular spongy vascular bone (otospongiosis). The abnormal bone fixates the stapes footplate, causing progressive conductive hearing loss.

Epidemiology: Predominantly in Caucasians; females > males (2:1); bilateral in 70-80%; hereditary (autosomal dominant with incomplete penetrance); may be activated by pregnancy.

Signs:

Paracusis Willisi (see below)
Schwartz's sign (see below)
Carhart's notch (see below)
Negative Rinne (BC > AC) with Weber lateralizing to worse ear
Tympanogram: Type As (shallow/stiff)
Absent stapedial reflexes
Pure tone audiogram: Rising audiogram (low frequencies affected first)

Symptoms:

Progressive, bilateral conductive hearing loss (most common)
Tinnitus (low frequency)
Paracusis Willisi
No ear discharge (dry ear)
Rarely: sensorineural component (cochlear otosclerosis)

13. Paracusis Willisi

The paradoxical ability of an otosclerotic patient to hear better in noisy surroundings than in quiet environments.

Explanation: Normal-hearing individuals unconsciously raise their voices in a noisy environment. The otosclerotic patient, who has conductive deafness, benefits from the louder speech, as environmental noise does not affect bone-conducted hearing (their cochlear reserve is intact). Hence they appear to hear better in noise.

Significance: Pathognomonic of otosclerosis (conductive hearing loss in general). It is not seen in sensorineural hearing loss because in SNHL, noise is equally disturbing.

15. Schwartz's Sign (Flamingo Pink Blush)

A flamingo pink blush (or reddish hue) seen through the anterior part of the tympanic membrane on otoscopic examination.

Basis: This is due to the increased vascularity of the actively remodeling (otospongiotic) bone over the region of the fissula ante fenestram (anterior to the oval window), seen through the translucent tympanic membrane.

Significance: Indicates active, vascular (otospongiotic) phase of otosclerosis. Correlates with more rapid progression of the disease. These patients may respond to sodium fluoride therapy.

Appearance: Pink blush anterior to the stapes, seen through the posterosuperior quadrant of the drum.

16. Carhart's Notch

A characteristic dip in bone conduction at 2000 Hz seen on the pure tone audiogram of patients with otosclerosis (stapes fixation).

Basis: It is a mechanical notch, not true sensorineural hearing loss. The fixation of the stapes footplate impairs the inertial bone conduction mechanism (the stapes normally vibrates to enhance bone-conducted sound at 2 kHz). After successful stapedectomy, the Carhart's notch largely disappears, confirming its mechanical origin.

Values: Typically 5 dB at 500 Hz, 10 dB at 1000 Hz, 15 dB at 2000 Hz, 5 dB at 4000 Hz.

Clinical importance:

Helpful diagnostic clue for otosclerosis
May falsely suggest a sensorineural component - do not over-interpret
Reverses (partially or fully) after stapedectomy

17. Management of Otosclerosis

Conservative:

Hearing aids (suitable for elderly, bilateral disease, cochlear otosclerosis)
Sodium fluoride: arrests active otosclerosis by suppressing enzymatic activity; used in active phase (Schwartz sign positive)

Surgical (definitive treatment):

Stapedectomy (Rosen's operation): Removal of the fixed stapes and replacement with a prosthesis.

Steps: Tympanotomy → Removal of stapes superstructure → Perforation/removal of stapes footplate → Placement of prosthesis (Teflon piston/wire-fat prosthesis) from the long process of incus to the oval window
Results: Excellent; restores hearing in 90-95% cases
Complications: Perilymph gusher, sensorineural loss (dead ear), tinnitus, facial nerve injury, taste disturbance

Stapedotomy (preferred now): A small hole (0.6-0.8 mm) is drilled in the footplate using a laser or microdrill, and a piston prosthesis is placed. Less traumatic than complete stapedectomy.

Contraindications to surgery: Only-hearing ear, Meniere's disease associated, active infection, severe SNHL.

18. Extracranial Complications of CSOM

Complications occurring outside the cranial cavity:

Mastoiditis - acute coalescent mastoiditis (most common extracranial complication)
Bezold's abscess - pus from mastoid tip perforates through the inner cortex of mastoid tip, tracks under sternocleidomastoid muscle into the neck
Citelli's abscess (Digastric/Occipital abscess) - pus tracks into the posterior belly of digastric
Subperiosteal (Postauricular) abscess - pus tracks through lateral cortex of mastoid, collects under periosteum behind the ear; pinna is pushed forward and downward
Zygomatic abscess - pus erodes zygomatic root, presents as swelling over cheek
Petrositis (Gradenigo's syndrome) - involvement of petrous apex; triad: otorrhea + retro-orbital/temporal pain (CN V) + diplopia (CN VI palsy)
Facial nerve palsy - from erosion of the fallopian canal
Labyrinthitis - serous or suppurative (circumscribed or diffuse); presents with vertigo
Neck abscess - rare

19. Intracranial Complications of CSOM

Extradural (epidural) abscess - pus between bone and dura; most common intracranial complication; may be asymptomatic
Subdural abscess - pus between dura and arachnoid; rare but serious
Meningitis - most common life-threatening intracranial complication
Brain abscess - temporal lobe (most common site from middle ear disease) or cerebellar abscess
Lateral (sigmoid) sinus thrombophlebitis (thrombosis) - Greisinger's sign seen (see below); presents with picket-fence fever, papilledema, headache
Otitic hydrocephalus - raised ICP with normal CSF; due to lateral sinus thrombosis impairing CSF absorption

20. Griesinger's Sign

Oedema and tenderness over the posterior part of the mastoid (over the mastoid emissary vein area), specifically posterior and inferior to the mastoid process.

Basis: In sigmoid sinus thrombophlebitis (lateral sinus thrombosis), the thrombosis extends into the mastoid emissary vein, causing thrombophlebitis of this vein. The resultant soft tissue inflammation produces the characteristic posterior mastoid swelling/oedema.

Significance: Pathognomonic sign of sigmoid/lateral sinus thrombosis as a complication of CSOM. (Note: spelled Griesinger in Dhingra, not Griensinger - but both spellings encountered in exams.)

21. Furunculosis of the Ear

Furunculosis (furuncle = acute staphylococcal infection of a hair follicle) of the external auditory canal.

Site: Confined to the cartilaginous (outer 1/3) of the EAC, as hair follicles and sebaceous glands are present only there.

Causative organism: Staphylococcus aureus

Clinical features:

Severe, throbbing otalgia - most intense pain; aggravated by jaw movement and tragal pressure
Tenderness on pressure over the tragus and on moving the pinna (distinguishes from AOM)
Canal blocked - conductive hearing loss
Low-grade fever, regional lymphadenopathy (pre-auricular, post-auricular nodes)
Otoscopy: Red, swollen, tender localized swelling in outer EAC; may see a central yellow point (pus)

Treatment:

Glycerine and ichthammol (10% glycerine + 2% ichthammol) wick - relieves pain and draws out pus
Analgesics (NSAIDs)
Systemic antibiotics (anti-staphylococcal): Cloxacillin/Amoxicillin-Clavulanate
Incision and drainage if pointing (under LA)
Treat predisposing factors: diabetes mellitus, furunculosis elsewhere

22. Bezold's Abscess

A deep neck abscess occurring as a complication of acute mastoiditis/CSOM, where pus from the mastoid air cells erodes through the medial (inner) surface of the mastoid tip and tracks under the attachment of the sternocleidomastoid muscle (SCM) into the neck.

Mechanism: The mastoid tip is pneumatized; pus erodes its thin medial cortex → enters the fascial space between SCM and digastric → tracks downward along the SCM muscle into the neck.

Clinical features:

Swelling in the upper neck (deep to SCM) on the affected side
Tender, indurated, fluctuant neck mass
Limited neck movement (torticollis - head tilted toward the affected side)
High fever, toxemia
Ear discharge (signs of CSOM/acute mastoiditis)
No postauricular swelling (unlike subperiosteal abscess)

Investigations: CT scan (defines extent of abscess and mastoid disease)

Treatment:

IV antibiotics
Surgical drainage of neck abscess (external cervical incision)
Mastoidectomy (to remove the source)

23. Tympanic Membrane

The tympanic membrane (TM) is a thin, semi-transparent, pearly grey, oval (slightly wider superoinferiorly than anteroposteriorly) membrane that separates the external auditory canal from the middle ear.

Dimensions: Approximately 9-10 mm in vertical diameter, 8-9 mm anteroposteriorly; tilted at an angle of 55° to the floor of the EAC.

Layers (3):

Outer layer: Continuation of EAC skin (keratinizing squamous epithelium)
Middle layer (fibrous layer): Radial fibers (outer) + circular fibers (inner); absent in pars flaccida
Inner layer: Continuation of middle ear mucosa (cuboidal/squamous epithelium)

Parts:

Pars tensa (lower 4/5): Has all 3 layers; taut and tense; has the cone of light
Pars flaccida (Shrapnell's membrane) (upper 1/5): Only 2 layers (no fibrous layer); lax; situated above the lateral process of malleus

Landmarks on otoscopy:

Handle (manubrium) of malleus (visible through TM)
Lateral process of malleus (seen as a white projection anterosuperiorly)
Anterior and posterior malleolar folds (marking pars flaccida above)
Umbo (tip of handle of malleus)
Cone of light (anteroinferior quadrant) - extends from umbo to 5 o'clock (right) / 7 o'clock (left)
Annulus fibrosus (thickened periphery)

Function: Transmits sound vibrations; acts as a resonator; protects middle ear.

24. Tests for Malingering (Non-organic/Functional Hearing Loss)

Malingering = deliberate feigning or exaggeration of hearing loss for secondary gain.

Tests:

Stenger's Test (most important):
- Principle: When two tones of same frequency are presented simultaneously to both ears, only the louder one is heard (Stenger's principle).
- Method: Tone presented to good ear at just above threshold, simultaneously a louder tone to "deaf" ear. A malingerer denies hearing anything (as they unconsciously hear only the loud tone in the "deaf" ear).
- Positive Stenger = malingering
Delayed Speech Feedback (Lee's Test):
- Speech is fed back to the patient after a 0.2-second delay through headphones.
- Normal hearing persons are disturbed and stammer.
- A malingerer with normal hearing will be disturbed; a truly deaf person will not.
Lombard's Test (Voice Reflex Test):
- Masking noise is introduced into both ears; a normal-hearing person unconsciously raises their voice (Lombard effect).
- A malingerer raises their voice (showing they can hear the noise); a truly deaf person does not.
ERA/BERA (Brainstem Evoked Response Audiometry):
- Objective test; does not require patient's cooperation.
- Most reliable test for malingering.
OAE (Otoacoustic Emissions):
- Objective; present if cochlea is normal.
Psychogalvanic Skin Response (PGSR):
- Classical objective test; measures skin resistance change as a conditioned response to sound.

25. Collaural Fistula (First Branchial Cleft Anomaly)

A congenital fistulous tract connecting the floor of the external auditory canal (or conchal bowl) to the neck (usually just below or at the level of the angle of the mandible or the submandibular region), representing a persistent remnant of the first branchial cleft.

Classification (Work's classification):

Type I: Ectodermal origin only; runs parallel to the EAC, lateral to the facial nerve
Type II (more common): Contains both ectoderm and mesoderm; opens in the neck near the angle of mandible and into the EAC; has a close relationship with the facial nerve

Clinical features:

Recurrent neck abscess near angle of mandible
Ear discharge (from EAC opening)
Pit or opening in EAC (superoanterior wall) and/or in neck
Facial nerve at risk

Treatment: Complete surgical excision (with parotidectomy if needed to identify facial nerve).

26. Nerve Supply of the External Ear

Auricle (Pinna):

Auriculotemporal nerve (branch of CN V3): Anterior surface, tragus, anterior helix
Lesser occipital nerve (C2): Upper posterior auricle
Greater auricular nerve (C2, C3): Lower posterior auricle and lobule - main nerve
Auricular branch of vagus (Arnold's nerve): Concha and posterior EAC (Hitselberger's sign)
Facial nerve (CN VII): Small area of auricle (concha) + posterior EAC skin

External Auditory Canal:

Outer 1/3 (cartilaginous): Auriculotemporal nerve (CN V3), Arnold's nerve (CN X)
Inner 2/3 (bony): Auriculotemporal nerve, Arnold's nerve (CN X), CN IX (Jacobson's nerve - small contribution)

Tympanic Membrane:

Outer surface: Auriculotemporal nerve (CN V3)
Inner surface: Tympanic branch of CN IX (Jacobson's nerve)

Clinical importance: Cough reflex on ear syringing (Arnold's nerve - CN X); referred otalgia mechanisms.

27. Radiological Views for the Ear

Law's View (Lateral oblique):
- Shows mastoid air cells; lateral wall of mastoid
- Used for: Mastoid disease, cellular pattern
Schuller's View (Modified Law's):
- Standard lateral oblique view at 25° caudal angulation
- Shows mastoid air cells, sigmoid sinus plate, tegmen
- Most commonly used routine view for mastoid
Stenver's View:
- Oblique view at 45°; 12° caudal tilt
- Shows: Petrous bone, IAM (internal auditory meatus), labyrinth, semicircular canals, cochlea
- Used for: Acoustic neuroma (asymmetry of IAM), labyrinthine disease
Towne's View (Half-axial):
- AP view, 30° caudal angulation
- Shows: Petrous apex, IAM (both sides for comparison), dorsum sellae
- Good for comparing IAM diameters bilaterally
Owen's View:
- Shows ossicular chain (malleus and incus), attico-antral region
Transorbital view:
- Shows IAM through orbit

CT Temporal Bone (High resolution CT - HRCT):

Now gold standard for ossicular chain, cholesteatoma, otosclerosis, labyrinthine abnormalities, fractures.

MRI:

Gold standard for acoustic neuroma, inner ear diseases.

28. MacEwen's Triangle (Suprameatal Triangle)

A surgically important landmark on the lateral surface of the mastoid, used to locate the mastoid antrum.

Boundaries:

Above: Posterior root of the zygomatic arch (suprameatal crest / temporal line)
Anteroinferiorly: Posterosuperior bony wall of the EAC (Spine of Henle anteriorly)
Posteriorly: A tangent drawn from the posterior wall of the EAC

Significance:

The mastoid antrum lies 1.5 cm deep to the suprameatal spine at the centre of this triangle (in an adult)
Used as a surface landmark to guide cortical mastoidectomy incision and antrum entry
In children, the antrum is more superficial (1 cm deep)
The anterosuperior wall of the triangle corresponds to the area overlying the antrum

Clinical use: In cortical mastoidectomy (Schwartze's operation), bone is removed within this triangle to enter the antrum.

29. Fistula Test

A test to detect the presence of an abnormal communication (fistula) between the middle ear and labyrinth, specifically a fistula in the bony wall of the lateral semicircular canal (most common site in CSOM/cholesteatoma).

Method:

Siegle's pneumatic speculum (or traction on the tragus) is used to alternately increase and decrease the air pressure in the EAC.
Positive pressure compresses the perilymph through the fistula → deviation of cupula → nystagmus and vertigo.

Positive Fistula Test:

Vertigo and nystagmus produced when pressure is applied (positive pressure causes nystagmus toward the same side; negative pressure away)

Interpretation:

Positive test = fistula likely present (e.g., lateral semicircular canal fistula in cholesteatoma)
The test can be positive without a true fistula (false positive): in active Meniere's disease, after labyrinthectomy
False negative: Fistula present but labyrinth is dead; or the fistula is blocked by granulation tissue

Tullio phenomenon: Sound-induced vertigo/nystagmus - related phenomenon due to dehiscent superior semicircular canal or fistula.

Surgical importance: A positive fistula test in CSOM is an indication of cholesteatoma eroding into the labyrinth - urgent surgical exploration warranted.

---All 29 short answers are compiled above as per Dhingra's ENT (RGUHS pattern). Here's a quick reference index:

#	Topic	Key Point
1	Referred Otalgia	Pain from remote sites via CN V, VII, IX, X, C2-C3
2	Acute Otalgia	Furunculosis (most severe), AOM, otitis externa
3	Causes of Pain in Ear	Primary (otogenic) + Secondary (referred)
4	BAHA	Osseointegrated titanium implant; bypasses outer/middle ear
5	Vestibular Schwannoma	Unilateral SNHL + tinnitus + vertigo triad; MRI gold standard
6	Hitselberger's Sign	Hypoesthesia posterior EAC wall - early sign of acoustic neuroma
7	Glomus Tympanicum	Vascular mass on promontory; pulsatile tinnitus; Brown's sign
8	Crocodile Tears	Aberrant facial nerve regeneration - eating triggers lacrimation
9	Exostosis EAC	Surfer's ear; bilateral, sessile; cold water etiology
10	Lermoyez Syndrome	Hearing improves after vertigo attack - variant of Meniere's
11	Treatment Acute Meniere's	Bed rest + Prochlorperazine/Diazepam + antiemetics
12	Otosclerosis	Otic capsule spongy bone; stapes fixation; bilateral CHL
13	Paracusis Willisi	Hears better in noise - pathognomonic of CHL/otosclerosis
15	Schwartz's Sign	Flamingo pink blush - active otosclerosis (over fissula ante fenestram)
16	Carhart's Notch	BC dip at 2000 Hz; mechanical; reverses post-stapedectomy
17	Management Otosclerosis	Stapedotomy (preferred)/Stapedectomy; hearing aid; NaF
18	Extracranial Complications CSOM	Mastoiditis, Bezold's, subperiosteal abscess, petrositis, labyrinthitis
19	Intracranial Complications CSOM	Extradural abscess, meningitis, brain abscess, sigmoid sinus thrombosis
20	Griesinger's Sign	Posterior mastoid oedema = sigmoid sinus thrombosis
21	Furunculosis	Outer 1/3 EAC; Staph aureus; tragal tenderness; glycerine-ichthammol wick
22	Bezold's Abscess	Pus through mastoid tip medial cortex into neck under SCM
23	Tympanic Membrane	3 layers; pars tensa + pars flaccida; cone of light anteroinferior
24	Tests for Malingering	Stenger's test (key); BERA (most reliable objective test)
25	Collaural Fistula	First branchial cleft remnant; EAC to neck; close to facial nerve
26	Nerve Supply External Ear	CN V3, CN VII, CN IX, CN X (Arnold's), C2-C3
27	Radiological Views	Schuller's (mastoid), Stenver's (petrous/IAM), Towne's (compare IAM)
28	MacEwen's Triangle	Suprameatal triangle; antrum 1.5 cm deep in adults
29	Fistula Test	Pneumatic pressure → vertigo/nystagmus = lateral SCC fistula

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