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Audiology Review: Preparing for the Praxis and Comprehensive Examinations
https://t.me/medicina_free
62
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CHAPTER 2 Anatomy, Physiology, and Relevant Pathologies
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Practice Questions
1. A patient is being evaluated for an osseointegrated device due to microtia, atretic ear canals, and
abnormal middle ear structures. The audiologist also notices craniofacial abnormalities (e.g., eyes
slant downward with a notch in the lower eyelid, small jaw and mouth) often seen in Treacher
Collins syndrome. Which pharyngeal arch is most likely implicated in this patient?
a. 1
b.
2
3
c.
4
d.
Explanation: Treacher Collins syndrome is a first arch syndrome; the first brachial arch is responsible
for the feature changes of the face and aspects of the ear, especially external and middle ears. Since
this patient was being evaluated for an osseointegrated device, a conductive component can be safely
assumed to be present, so a is the correct answer.
2. At what gestational age is the cochlea fully developed?
a. 6 weeks
b. 12 weeks
c. 18 weeks
d. 24 weeks
Explanation: The cochlea begins to develop at approximately 7 weeks (one cochlear turn). At 11
weeks, the cochlear turns are completed, and the following week, cochlear sensory cells are present. The
cochlea reaches adult size (i.e., full development) by 20 weeks. Thus, the best answer is d (24 weeks).
3. Which of the following is considered a fine structure mechanism within the auditory system:
a. Malleus
b. Modiolus
c. Tectorial membrane
Reissner’s membrane
d.
Explanation: The fine structure refers to the cochlea mechanisms responsible for the conversion of
energy from mechanical to electrochemical. The malleus continues the mechanical transfer of energy
from the tympanic membrane to the stapes. Modiolus is simply part of the cochlear osseous structure
and does not contribute to the transfer of energy. In this instance, the ONLY structure involved in
conversion of energy from hydrodynamic to electrical is the tectorial membrane, which is where the
hair cells of the stereocilia are embedded . Thus, c is the correct answer.
4. What region of the basilar membrane will vibrate maximally for 100 Hz tone?
a. Apical/apex
b. Basal/base
c. Mid-basal/base
d. None of the above
Audiology Review: Preparing for the Praxis and Comprehensive Examinations
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Explanation: The basilar membrane is tonotopically organized and is less stiff and compliant at the
apex/apical portion, vibrating best with low-frequency signals. Despite not having specific information
about the age or frequency response of the cochlea, a is the best answer as the apical/apex portion of
the cochlear membrane because it vibrates best in the low frequency similar to 100 Hz.
5. The auditory system serves as a transducer of sensory information. Where does this transduction
take place?
a. Sound entering the external auditory meatus after being funneled by the pinna
b.
Fluid filling the middle ear space due to Eustachian tube dysfunction
Stimulation of hair cells on the basilar membrane in response to sound
c.
d.
The ear canal changing an auditory event into an electrical signal
Explanation: Transduction refers to the conversion of energy from mechanoreceptive as initiated at the
cochlear hair cells of the stereocilia contacting or embedded into the tectorial membrane and anchored
at the basilar membrane within the organ of Corti to become an equivalent electrical waveform. In this
question, the best answer is c, which will ultimately result in a conversion of energy from mechanical
to electrical, which allows delivery of the signal to the sensory system.
6. The definition of “matching” relatively low-resistant airborne signals to a mechanism that is
highly resistant to airborne signals would be relevant for the following term (choose one that is
most appropriate):
a.
Impairment matching
Impedance matching
b.
c. Incident matching
d. Impediment matching
Explanation: The major function of the middle ear is to match very low-resistance airborne sounds to
the highly resistant fluid contained in the inner ear. This is completed through the mechanical action
of the ossicular chain in the middle ear. The best answer for this question is b, which transfers energy
from sound traveling in the middle ear through the three major dynamic mechanisms (malleus, incus,
and stapes) that through their unified actions ensure very little loss of energy as sound travels into the
oval window.
7. One of the structures found within the organ of Corti is:
a. Reissner’s membrane
b. Malleus
c. Pars flaccida
d. Reticular lamina
Explanation: The listing of possible answers contains mechanisms that range from the tympanic
membrane, middle ear, and the larger cochlea. Not only by deductive reasoning through elimination,
the stiff reticular lamina/membrane extends from the outer hair cells to the Hensen’s cells — all reside
within the organ of Corti so the correct answer is d.
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8. What is an important characteristic of the outer hair cells?
a.
Connected to all Type I spiral ganglia
Responsible for cochlear amplification
b.
c.
Structurally the strongest hair cell
Significant afferent connections
d.
Explanation: The outer hair cells remain stiff when displaced, but the stiffness varies with potential
discharges. They also possess contractile proteins and are populated with more stereocilia at the base
than the apex. Though outer hair cells have very few afferent connections, they have the most efferent
connections. Their electromotile abilities create the cochlear amplifier so that responses to low-level
stimuli are enhanced. Responses a, c, and d are characteristics of the inner hair cells, but this question
pertains to outer hair cells. Therefore, the best answer would be b.
9. Choose the most appropriate choice of term that would fit the following definition: the
frequency at which the lowest amount of energy is needed to stimulate the neural response.
a. Cochlear amplifier
b. Low frequency
c. Characteristic frequency
d. Compound action potential
Explanation: The key terms to guide the reader are lowest amount of energy and stimulate the neural
response. Low frequency is neither a relevant nor a logical response. Inarguably, the cochlear amplifier
and compound action potential are important in the transduction of energy, but they do not relate to
creating more or less energy to trigger the neural response. Therefore, the only logical and relevant term
used for energy use at the neural level is characteristic frequency or c.
10. Which of the following is the reason that the frequency/telephone theory is unable to explain all
of frequency encoding abilities displayed by the auditory system?
a. Neural refractory period
b. Neural restoration period
c. Not all neurons fire at the same place in a cycle
d. Neural fine tuning is greater than what would be expected
Explanation: Though it only lasts a few milliseconds, the neural refractory period can potentially
impact the temporal coding of acoustic stimuli by auditory neurons; due to this, the higher frequencies
cannot be adequately encoded by the frequency/telephone theory alone. The volley principle involves
different neurons firing at the same place in alternating cycles and the place theory is driven by the
traveling wave, which has been shown to have broader areas of excitation than are psychophysically
measured. Thus, the best answer is a.
Audiology Review: Preparing for the Praxis and Comprehensive Examinations
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Appendix Key
ABR: auditory brainstem response; ANSD: auditory neuropathy spectrum disorder; Audio: audiometry;
BPPV: benign paroxysmal positional vertigo; CHARGE: coloboma, heart defects, atresia choanae (also
known as choanal atresia), growth retardation, genital abnormalities, and ear abnormalities; CHL: conductive hearing loss; CULLP: congenital unilateral lower lip palsy; ET: Eustachian tube; HL: hearing
loss; MEMR: middle ear muscle reflexes (acoustic reflexes); MHL: mixed hearing loss; OAEs: otoacoustic emissions; SCC: semicircular canals; SNHL: sensorineural hearing loss; TM: tympanic membrane;
Tymps: tympanometry; VNG: vestibulonystagmography; WNL: within normal limits.
CHAPTER 2 Anatomy, Physiology, and Relevant Pathologies
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Appendix 2–A
Outer Ear Disorders
ETIOLOGY AND
DISORDER
PATHOLOGY SYMPTOMS DIFFERENTIAL DIAGNOSIS
67
Atresia Congenital malformation
of the external auditory
canal due to interrupted
development of the outer
ear
Type A — meatal atresia
Type B — partial atresia
Type C — total atresia
Type D
atresia
Cerumen
impaction
Exostoses Broad, round, bony
Cerumen that has been
prevented from naturally
exiting out of EAC
growths that occur in the
osseous portion of the
EAC
— hypopneumatic
Visible abnormalities
(often in conjunction
with microtia and
other craniofacial
abnormalities)
Speech and language
delays
Possible inflammation,
otalgia, and/or otorrhea
Otalgia/discomfort/
itchiness
Hearing loss
Primarily asymptomatic
Hearing loss if large
enough
Otalgia
Cerumen impaction
Otitis externa
Otoscopy:
Tymps: Small ECV
MEMR:
Audio: CHL
OAEs: Reduced to absent
Otoscopy: partially or fully
occluding cerumen
Tymps:
ECV
MEMR: Conductive pattern
Audio: CHL (can be mixed)
OAEs:
Case Hx:
to cold temperatures (e.g.,
swimming, diving)
Otoscopy: Abnormal broad
round growths deep in canal
Tymps: Type A
MEMR: Consistent with
audio
Abnormal EAC
Conductive pattern
Type B with small
Reduced to absent
report of exposure
Audio: Possible CHL
OAEs: Consistent with audio
continues
Audiology Review: Preparing for the Praxis and Comprehensive Examinations
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APPENDIX 2–A. continued
ETIOLOGY AND
DISORDER
PATHOLOGY SYMPTOMS DIFFERENTIAL DIAGNOSIS
Foreign bodies Insects, small toys,
earrings/earring backs,
beads, etc. either placed
or volitionally entered
into EAC
Furunculosis Raised, reddish lesions at
the base of hair follicles
on the outer EAC
Herpes
zoster oticus
(shingles)
Lesions/blisters on
the pinna as a result
of chicken pox virus;
swelling on side of face
Otalgia/discomfort
Audible movement
Tactile perception
Otoscopy: Abnormal
Tymps:
Depends on if the
foreign body perforated the
TM; possibly Type A, possibly
Type B with small or large ear
canal volume
MEMR: Consistent with
audio and tymps
Audio:
Possible CHL
OAEs: Consistent with audio
Otalgia Otoscopy:
Tymps: Type A
MEMR: WNL
Audio:
Normal hearing
OAEs: WNL
Otalgia
Facial weakness/paralysis
Erythema
Otoscopy:
Tymps:
Type A
MEMR: Possibly elevated
Abnormal
Abnormal
Microtia Small or misshapen pinna
(e.g., peanut)
Anotia — complete
absence of pinna
Hearing loss
Visible abnormalities
(often co-occurs with
other anomalies such as
atresia and craniofacial
abnormalities)
Audio: SNHL
OAEs:
Consistent with audio
Otoscopy: Abnormal pinna
Tymps: Depends on
comorbidities; microtia in
isolation would yield type A
tymps
MEMR: Depends on
comorbidities; microtia in
isolation would yield normal
MEMR
Audio: Depends on
comorbidities; microtia in
isolation would yield normal
hearing
OAEs: Consistent with audio
CHAPTER 2 Anatomy, Physiology, and Relevant Pathologies
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ETIOLOGY AND
DISORDER
PATHOLOGY SYMPTOMS DIFFERENTIAL DIAGNOSIS
69
Osteoma Pedunculated benign
tumors in the osseous
portion of the EAC
Otitis externa Infection of the outer ear
(ear canal and/or pinna)
caused by bacteria or
fungus
Can progress to
necrotizing
Primarily asymptomatic
Hearing loss if large
enough
Otalgia
Vertigo
Cerumen impaction
Otitis externa
Otalgia
Otorrhea
Possible fever
Otoscopy:
Abnormal growths
with narrow base
Tymps:
Type A
MEMR: Consistent with
audio, possible conductive
pattern
Audio:
Normal hearing,
possible CHL
OAEs:
Otoscopy:
Tymps:
Consistent with audio
Abnormal
Type A (dependent on
EAC edema)
MEMR: WNL, possible
conductive pattern (dependent
on EAC edema)
Audio: Normal hearing,
possible CHL (dependent on
EAC edema)
OAEs:
Consistent with audio
Perichondritis Infection of pinna
resulting typically from
trauma
Otalgia
Erythema
Edema
Otoscopy: Reddened, swollen
pinna with normal EAC
Tymps:
MEMR:
Type A
WNL
Audio: Normal hearing
OAEs: Consistent with audio
Audiology Review: Preparing for the Praxis and Comprehensive Examinations
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Appendix 2–B
Middle Ear Disorders
ETIOLOGY AND
DISORDER
PATHOLOGY SYMPTOMS DIFFERENTIAL DIAGNOSIS
Cholesteatoma Overproduction of
keratin from squamous
cell epithelium
within the middle
ear, most often in the
epitympanum
Can be caused by
chronic inflammation
and infection of the
middle ear (acquired)
or related to embryonic
epithelial cell nests
Most often unilateral
Disarticulation
of the ossicular
chain
Continuity of the ossicles
becomes disrupted,
most often at the
incudostapedial joint
Possibly related to
congenital abnormalities,
ear infections, or trauma
Chronic middle ear
issues
Aural fullness
Otalgia
Smelly otorrhea
Numbness or muscle
weakness of affected side
Hearing loss
Dizziness
Primarily asymptomatic
Hearing loss
Otoscopy: White mass behind
TM; debris in EAC
Tymps:
MEMR:
Audio: Unilateral CHL or
MHL with normal speech
OAEs:
VNG: ordered if dizzy
Otoscopy: WNL
Tymps: Type Ad
MEMR:
contralaterally
Audio:
OAEs:
Type Ad or B
Conductive pattern
Reduced to absent
Absent
CHL (can be mixed)
Absent
Eustachian tube
dysfunction
ET fails to open or
becomes chronically
closed, which prevents
the middle ear from
ventilating
Creates excess negative
pressure, which can
lead to other middle ear
disorders
Aural fullness
Possible sinus issues
Possible hearing loss and
tinnitus on affected side
Autophony
Difficulty popping ears
Otoscopy:
Tymps:
MEMR: Conductive pattern
ETF: No/minimal change in
peak pressure for Valsalva or
Toynbee
Audio: Low-frequency CHL
OAEs: Reduced to absent
WNL or retraction
Type C
CHAPTER 2 Anatomy, Physiology, and Relevant Pathologies
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ETIOLOGY AND
DISORDER
PATHOLOGY SYMPTOMS DIFFERENTIAL DIAGNOSIS
71
Glomus tumor
(paraganglioma)
Jugulare or tympanicum
Arise from paraganglion
cells in jugular bulb or
adjacent to Arnold’s or
Jacobson’s nerve
Otitis media Inflammation of the
middle ear creates
effusion behind the
TM, which can develop
bacterial infection
Can be acute, serous,
chronic, recurrent
Primarily caused by ET
dysfunction
Pulsatile tinnitus
Aural fullness
Otalgia
Facial nerve weakness
Hoarse voice &
dysphagia
Vertigo
Otalgia
Otorrhea
Aural fullness
Possible history of recent
respiratory infection
Possible facial nerve
palsy (rare)
Pulling ears (child)
Otoscopy:
Red mass behind
TM; Brown’s sign
Tymps:
Match heartbeat (can
see with decay protocol)
MEMR:
Audio:
Consistent with audio
Unilateral CHL or
MHL
OAEs:
VNG:
Otoscopy:
Absent unilateral
Order if dizzy
Cloudy, bubbles,
redness, inflammation;
landmarks not visible
Tymps: Type B
MEMR: Conductive pattern
Audio: Low-frequency
or flat CHL with normal
speech scores (at elevated
presentation levels)
OAEs: Absent
Otosclerosis Metabolic alteration of
temporal bone in the otic
capsule — stapes footplate
becomes mineralized
around oval window,
causing stapes fixation
Perforation Perforation in the pars
flaccida or pars tensa of
TM
Related to trauma,
infections, or surgery
Autophony
Difficulty hearing when
chewing
Possible tinnitus
Trouble in background
noise
Hearing loss
Related to hormone
changes; women in
30s/40s, after giving
birth
Otalgia
Hearing loss
Possible history of head
trauma
Possible blood or
drainage in EAC
Otoscopy:
Schwartze’s sign
(TM appears reddish)
Tymps:
Type A or As
MEMR: Upward deflection
Tuning Fork: Weber (to
CHL), Rinne (CHL-louder
on mastoid)
Audio: Carhart’s notch (CHL
with SNHL at 2 kHz), can
progress into flat MHL
OAEs: Consistent with audio
Otoscopy:
Tymps:
Visible hole in TM
Type B with large
ECV
MEMR: Conductive pattern
Audio: Unilateral
low-frequency CHL
OAEs: Absent unilateral
continues
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