404. An 89-year-old man has noticed that his hearing has gradually worsened with aging. The examining physician applies a vibrating tuning fork to his right mastoid process. The moment the sound can no longer be heard, the fork is held near the auditory meatus and the patient can again hear it. His deafness has probably developed because of which of the following?
a. Calcification of ligaments stabilizing the ossicles
b. Weakness of the tensor tympani
c. Neuronal degeneration
d. Weakness of the stapedius muscle
e. Granulation tissue in the middle ear
405. A 65-year-old diabetic woman has aphasia secondary to a stroke involving the inferior division of the left middle cerebral artery. Her hearing is intact. Which of the following correctly reflects why dominant temporal lobe infarction will not produce complete deafness?
a. There is no temporal lobe representation for hearing.
b. Each cochlear nucleus projects to both temporal lobes.
c. Deafness results with nondominant hemisphere damage.
d. Both thalamic and temporal lobe damage must occur.
e. Both brainstem and temporal lobe damage must occur.
406. A 72-year-old man is having difficulty hearing. He is being tested with a tuning fork. If he has disease of the middle ear, sound transmitted strictly by air conduction will be perceived as which of the following?
a. Louder than that transmitted by bone conduction
b. Quieter than that transmitted by bone conduction
c. Lower pitched than that transmitted by bone conduction
d. Higher pitched than that transmitted by bone conduction
e. Oscillating between high and low pitch
407. A 13-year-old girl has a severe case of mastoiditis. Despite treatment, she develops a fluent aphasia. Her aphasia is most likely the result of extension of the infection into which portion of the brain?
a. Frontal lobe
b. Parietal lobe
c. Temporal lobe
d. Occipital lobe
e. Cerebellum
408. A 19-year-old soldier stationed in Iraq was exposed to an exceptionally loud nearby explosion. There was an initial severe loss of hearing followed by partial recovery. Which of the following best describes her hearing loss?
a. High-tone sensorineural loss
b. Low-tone sensorineural loss
c. High-tone conductive loss
d. Low-tone conductive loss
e. Central deafness
409. A 79-year-old woman is brushing her teeth when she has an intense sensation that the room is moving as if she were on a ship. Examination and testing reveal a cerebellar stroke. Cerebellar damage may be associated with severe vertigo if the tissue damaged is in the distribution of which of the following arteries?
a. Superior cerebellar artery
b. Posterior inferior cerebellar artery (PICA)
c. Anterior inferior cerebellar artery (AICA)
d. Anterior spinal artery
e. Posterior cerebral artery
410. A 62-year-old man has started getting a haircut every week. Whenever he lays his head back to have his hair washed, he has the sensation of spinning. With vertigo that develops on extreme extension or rotation of the head, the patient probably has insufficiency in which of the following?
a. Left subclavian artery
b. Internal carotid arteries bilaterally
c. Vertebrobasilar system
d. Internal maxillary artery
e. Innominate artery
411. A 45-year-old left-handed man has had recurrent attacks of “dizziness.” He describes the sensation of feeling the room spinning. The episodes occur abruptly and usually last for approximately 45 minutes. The dizziness occurs about once per month, but may happen more frequently. There is often accompanying ringing and decreased hearing in one ear. Which of the following most accurately describes the early hearing loss in this disease?
a. Overall frequencies
b. Primarily over high frequencies
c. Primarily over middle frequencies
d. Primarily over low frequencies
e. In virtually no patients
412. A 52-year-old diabetic man on multiple medications develops vertigo. Which of the following may cause a toxic labyrinthitis?
a. Promethazine
b. Penicillin
c. Dimenhydrinate
d. Acetylsalicylic acid
e. None of the above
413. A 50-year-old man is being evaluated for tinnitus. It is worse on some days than others. Which of the following should he be told may exacerbate the tinnitus?
a. Alcohol
b. Aspirin
c. Glucose
d. Diazepam
e. Steroids
414. A 26-year-old man has multiple hyperpigmented lesions, each over 1.5 cm. Which of the following tumors is most likely to occur in this patient?
a. Medulloblastoma
b. Acoustic schwannoma
c. Neurofibroma
d. Ependymoma
e. Meningioma
415. A 30-year-old woman has progressive hearing loss. A magnetic resonance imaging (MRI) reveals bilateral acoustic schwannomas (neuromas). Which of the following is the most likely diagnosis?
a. Type 1 neurofibromatosis (von Recklinghausen disease)
b. Type 2 neurofibromatosis
c. Meningeal carcinomatosis
d. Multifocal meningiomas
e. Disseminated ependymomas
416. People with traumatic head injury are highly susceptible to subsequent impaired sense of smell. The olfactory cortex in humans is located in which of the following locations?
a. Anterior perforated substance
b. Lateral olfactory gyrus (prepiriform area)
c. Posterior third of the first temporal gyrus
d. Angular gyrus
e. Calcarine cortex
417. The hypogonadism and anosmia of Kallmann syndrome usually attract medical attention during which stage of life?
a. The newborn period
b. Infancy
c. Childhood
d. Adolescence
e. Adult life
418. A 22-year-old woman is involved in a head-on motor vehicle accident. She was not wearing a seat belt, and she received a skull fracture when her head hit the windshield. By what mechanism would this patient develop anosmia?
a. Subarachnoid blood causes pial adhesions on the olfactory nerve.
b. Injury to the temporal tip injures the olfactory cortex.
c. Torsion on the brainstem injures trigeminal tracts.
d. Shearing forces sever filaments of the receptor cells as they cross the cribriform plate.
e. Traction on the chorda tympani damages fibers as they course through the skull.
419. A 45-year-old man has noticed over the past 6 months that his sense of smell is not as sensitive as it used to be. On examination he has unilateral anosmia, ipsilateral optic atrophy, and contralateral papilledema. Which of the following is the most likely diagnosis?
a. Pseudotumor cerebri
b. Multiple sclerosis (MS)
c. Olfactory groove meningioma
d. Craniopharyngioma
e. Nasopharyngeal carcinoma
Questions 420 to 423
Choose the condition that best matches the clinical scenario. Each lettered option may be used once, more than once, or not at all.
a. Ménière disease
b. Cholesteatoma
c. Vestibular schwannoma
d. Benign positional vertigo (BPV)
e. Aminoglycoside toxicity
f. Salicylate toxicity
g. Vestibular neuronitis
h. Posttraumatic vertigo
i. Vertebral artery occlusion
j. Bilateral vestibular hypofunction
k. Bell palsy
420. A 60-year-old woman has intermittent dizzy spells during the day. Her symptoms are worse when she turns her head to the left, to the point that she tends to keep her head stiff, looking forward. She becomes particularly dizzy when she lies down in bed at night or turns onto her left side. She occasionally wakes up in the middle of the night feeling dizzy. She had a similar experience 2 years ago, which lasted for 2 weeks and then spontaneously resolved. She has otherwise felt well, and her hearing is normal. On examination, putting her head back and the left ear down elicits a feeling of dizziness and nausea associated with rotatory nystagmus, which lasts for 15 seconds and then resolves.
421. A 34-year-old investment banker has intermittent episodes of vertigo associated with a feeling of fullness in his right ear. These last for several hours. He has had progressive hearing loss in the right ear. There are no other symptoms. He takes no medications and has no history of head trauma.
422. A 47-year-old woman with a history of orthotopic heart transplantation 6 months ago has had a complicated postoperative course and was readmitted 3 months ago with pneumonia. She was treated with gentamicin, vancomycin, and clindamycin, as well as her usual regimen of immunosuppressant medications, lipid-lowering drugs, and aspirin. Since then, she has had severe but stable disequilibrium, with inability to walk without a cane. There has been no hearing loss or weakness.
423. A 72-year-old man awakens with severe vertigo associated with nausea and vomiting. He is ataxic. Over the next several days, he develops numbness of the left side of his body, dysphagia, and hiccups. On examination, he has a left homonymous hemianopsia, left-sided sensory loss, dysmetria with the right hand, and no weakness. He has had intermittent episodes of dizziness for the past month.