Vestibular Neuritis — MCQs
A 45-year-old female presents with hearing loss, vertigo, and tinnitus in her right ear. Which condition is most likely?
A 47-year-old man presents to the emergency room with symptoms of dizziness and difficulty walking. He describes his dizziness as a spinning sensation of the room with associated nausea and vomiting. Which of the following findings suggests the vertigo is peripheral in origin?
Evidence based therapy of Bell's palsy include(s):
Which of the following can cause unilateral sensorineural hearing loss?
In a patient with right vestibular neuronitis, what will be the finding on the head impulse test?
All are true about vestibular neuritis EXCEPT:
Treatment of choice for CSOM with vertigo and facial nerve palsy is:
Epley's maneuver is used in the treatment of:
Meniere's disease is characterized by which of the following pathophysiological changes?
Which of the following is a true differential cause of referred otalgia?
Vestibular Neuritis Indian Medical PG Practice Questions and MCQs
Question 1: A 45-year-old female presents with hearing loss, vertigo, and tinnitus in her right ear. Which condition is most likely?
- A. Acoustic neuroma
- B. Meniere's disease (Correct Answer)
- C. Chronic otitis media
- D. Otosclerosis
Explanation: ***Meniere's disease*** - This condition classically presents with the triad of **vertigo**, **tinnitus**, and **fluctuating sensorineural hearing loss**, often in one ear. - The symptoms are thought to be caused by an excess of fluid, known as **endolymphatic hydrops**, in the inner ear. *Acoustic neuroma* - While it can cause **unilateral hearing loss** and **tinnitus**, it typically causes more persistent, progressive symptoms and **vertigo is less common or severe** than in Meniere's. - An acoustic neuroma is a **benign tumor** on the vestibulocochlear nerve (cranial nerve VIII) that can also cause **facial numbness** or weakness in later stages. *Chronic otitis media* - This condition primarily causes **conductive hearing loss** due to damage to the middle ear structures and often involves **tympanic membrane perforation** and **otorrhea**. - It does not typically present with vertigo unless there is an erosion into the inner ear (labyrinthitis), and **tinnitus is less prominent** than in Meniere's disease. *Otosclerosis* - This condition primarily causes **progressive conductive hearing loss** in younger to middle-aged adults, often bilaterally, due to abnormal bone growth in the middle ear. - While **tinnitus can occur**, **vertigo is rare** and not a primary symptom, distinguishing it from Meniere's disease.
Question 2: A 47-year-old man presents to the emergency room with symptoms of dizziness and difficulty walking. He describes his dizziness as a spinning sensation of the room with associated nausea and vomiting. Which of the following findings suggests the vertigo is peripheral in origin?
- A. optic neuritis
- B. tinnitus (Correct Answer)
- C. bidirectional nystagmus
- D. vertical nystagmus
Explanation: ***tinnitus*** - The presence of **tinnitus**, along with **hearing loss** and **vertigo**, is highly suggestive of a peripheral cause of vertigo, such as **Meniere's disease** [1]. - Peripheral vertigo disorders often involve the **inner ear** structures, which are responsible for both balance and hearing [1]. *optic neuritis* - **Optic neuritis** is an **inflammation of the optic nerve** and is a neurological symptom typically associated with **central nervous system disorders**, such as **multiple sclerosis**. - It does not directly cause vertigo, although neurological conditions can present with balance disturbances. *bidirectional nystagmus* - **Bidirectional nystagmus** (nystagmus that changes direction) is a strong indicator of **central vertigo**, often caused by lesions in the brainstem or cerebellum [2]. - Peripheral nystagmus is typically **unidirectional** and horizontal or rotatory. *vertical nystagmus* - **Vertical nystagmus** (up-beating or down-beating) is almost always a sign of **central vertigo**, indicating damage to the brainstem or cerebellum [2]. - Peripheral vestibular lesions typically cause **horizontal or torsional nystagmus**.
Question 3: Evidence based therapy of Bell's palsy include(s):
- A. Steroid (Correct Answer)
- B. Facial nerve massage
- C. Acyclovir
- D. Facial nerve stimulation
Explanation: ***Steroid*** - **Corticosteroids**, such as prednisone, are the mainstay of treatment for Bell's palsy, particularly when initiated early (within 72 hours of symptom onset) [1]. - They work by reducing **inflammation and swelling** of the facial nerve, which can alleviate compression and promote recovery. *Facial nerve massage* - While supportive therapies like physical therapy can be helpful for **muscle re-education** and preventing contractures, facial nerve massage itself is not an evidence-based therapy for improving nerve function in acute Bell's palsy. - Its efficacy in **nerve regeneration** or speeding recovery has not been scientifically proven. *Acyclovir* - **Antivirals** like acyclovir or valacyclovir are sometimes used in conjunction with steroids if a **herpes simplex virus (HSV) etiology** is suspected, but their standalone use for Bell's palsy is not evidence-based and their benefit in addition to steroids is debated [1]. - The primary evidence points to a viral etiology in some cases, but the direct benefit of antivirals over steroids alone is not consistently robust across studies. *Facial nerve stimulation* - **Electrical stimulation** of the facial nerve is not recommended and may even be harmful in the acute phase of Bell's palsy. - It has not been shown to improve outcomes and can potentially impede natural nerve regeneration or cause **synkinesis** [1].
Question 4: Which of the following can cause unilateral sensorineural hearing loss?
- A. Coronavirus
- B. Pertussis
- C. Rotavirus
- D. Acoustic neuroma (Correct Answer)
Explanation: ***Acoustic neuroma*** - An **acoustic neuroma** (vestibular schwannoma) is a benign tumor that grows on the **vestibulocochlear nerve** (cranial nerve VIII), which can compress the nerve and cause progressive unilateral sensorineural hearing loss. - Other associated symptoms often include **tinnitus** and **balance disturbances** (vertigo or unsteadiness). *Coronavirus* - While some reports suggest a rare association between **COVID-19** and sudden sensorineural hearing loss due to viral inflammation or vascular compromise, it is not a common or definitive cause of progressive unilateral hearing loss. - Hearing loss directly due to coronavirus infection is typically acute and bilateral, rather than chronic and unilateral. *Pertussis* - **Pertussis** (whooping cough) is a bacterial respiratory infection that does not typically cause sensorineural hearing loss. - Complications are primarily pulmonary, neurological (e.g., seizures due to hypoxia), or nutritional, not otological. *Rotavirus* - **Rotavirus** causes severe gastroenteritis, particularly in infants and young children. - There is no established link between rotavirus infection and sensorineural hearing loss.
Question 5: In a patient with right vestibular neuronitis, what will be the finding on the head impulse test?
- A. Head turned to right, corrective saccade to the left (Correct Answer)
- B. Head turned to left, corrective saccade to the right
- C. Head turned to right, no corrective saccade
- D. Head turned to left, no corrective saccade
Explanation: ***Head turned to right, corrective saccade to the left*** - In **right vestibular neuronitis**, the right vestibular apparatus is impaired, affecting the **vestibulo-ocular reflex (VOR)** on that side. - During the head impulse test, when the head is rapidly turned **to the right** (toward the affected side), the impaired VOR cannot maintain eye fixation on the target. - The eyes initially move **with the head** (to the right), then a visible **corrective saccade** (catch-up saccade) brings them **back to the left** to refixate on the target. - This corrective saccade is the **hallmark positive finding** in head impulse test for right vestibular dysfunction. *Head turned to left, corrective saccade to the right* - This would indicate a **left vestibular lesion**, not right vestibular neuronitis. - When turning the head to the left with left vestibular dysfunction, a corrective saccade to the right would be observed. *Head turned to right, no corrective saccade* - This would indicate **normal VOR function** on the right side. - A normal response shows no corrective saccade because the eyes maintain fixation throughout the head turn. - This is the **opposite** of what is expected in right vestibular neuronitis. *Head turned to left, no corrective saccade* - This indicates normal VOR function on the left side. - In right vestibular neuronitis, turning the head to the left (away from the affected side) typically shows **normal VOR** with no corrective saccade needed.
Question 6: All are true about vestibular neuritis EXCEPT:
- A. Horizontal nystagmus
- B. Positive head thrust
- C. Vertical nystagmus (Correct Answer)
- D. Normal hearing
Explanation: ***Vertical nystagmus*** - **Vestibular neuritis** primarily affects the **horizontal semicircular canal** and superior vestibular nerve, leading to **horizontal or rotational nystagmus**, not vertical. - **Vertical nystagmus** is often indicative of a **central lesion** rather than a peripheral vestibular disorder like neuritis. *Horizontal nystagmus* - This is a characteristic finding in **vestibular neuritis**, where the **nystagmus is usually horizontal or rotatory** and beats away from the affected side. - The nystagmus typically **increases in intensity** when looking in the direction of the fast phase. *Positive head thrust* - A **positive head thrust test** (or **head impulse test**) is a hallmark of **peripheral vestibular dysfunction**, including vestibular neuritis. - It demonstrates a **saccadic corrective eye movement** when the head is quickly turned towards the affected side, indicating impaired vestibulo-ocular reflex. *Normal hearing* - **Vestibular neuritis** specifically involves inflammation of the **vestibular nerve**, sparing the cochlear nerve. - Therefore, patients with vestibular neuritis typically **maintain normal hearing**, differentiating it from labyrinthitis.
Question 7: Treatment of choice for CSOM with vertigo and facial nerve palsy is:
- A. Myringoplasty
- B. Antibiotics and labyrinthine sedative
- C. Immediate mastoid exploration (Correct Answer)
- D. Labyrinthectomy
Explanation: ***Immediate mastoid exploration*** - Vertigo and facial nerve palsy in the context of CSOM (Chronic Suppurative Otitis Media) indicate **intracranial complications** or significant **bone erosion** by the cholesteatoma, necessitating urgent surgical intervention. - **Mastoid exploration** allows for removal of the cholesteatoma, drainage of infection, and decompression of the facial nerve, preventing irreversible damage and life-threatening complications. *Myringoplasty* - This procedure involves **repairing the tympanic membrane** (eardrum) and is primarily performed for simple perforations without labyrinthine involvement or facial nerve complications. - It would not address the underlying pathology of **cholesteatoma erosion** or the serious symptoms of vertigo and facial nerve palsy. *Antibiotics and labyrinthine sedative* - While antibiotics may be part of the management for active infection, they alone cannot resolve an extensive **cholesteatoma** causing bone destruction and nerve compression. - **Labyrinthine sedatives** might temporarily relieve vertigo but do not treat the causative disease process, which requires surgical intervention. *Labyrinthectomy* - This procedure involves **destroying the labyrinth** to alleviate intractable vertigo, typically reserved for severe, unilateral Meniere's disease or non-functioning labyrinths. - It is a **destructive procedure** that would result in complete hearing loss and would not address the underlying **cholesteatoma** or the facial nerve palsy.
Question 8: Epley's maneuver is used in the treatment of:
- A. BPPV (Benign paroxysmal positional vertigo) (Correct Answer)
- B. Infective labyrinthitis
- C. Cervical spondylosis
- D. Tinnitus
Explanation: ***BPPV (Benign paroxysmal positional vertigo)*** - The **Epley's maneuver** is a repositioning procedure specifically designed to treat **benign paroxysmal positional vertigo (BPPV)** by moving displaced otoconia out of the semicircular canals. - BPPV is characterized by brief episodes of **vertigo** triggered by specific head movements. *Infective labyrinthitis* - **Infective labyrinthitis** is an inflammation of the inner ear, typically caused by a viral or bacterial infection, leading to vertigo, hearing loss, and tinnitus. - Its treatment involves antibiotics or antivirals and symptomatic relief, not physical maneuvers. *Cervical spondylosis* - **Cervical spondylosis** is a degenerative condition affecting the neck vertebrae and discs, causing neck pain, stiffness, and sometimes neurological symptoms. - Treatment focuses on physical therapy, pain management, and sometimes surgery, not the Epley's maneuver. *Tinnitus* - **Tinnitus** is the perception of noise or ringing in the ears without an external source, often a symptom of an underlying condition. - Management involves addressing the underlying cause, sound therapy, and cognitive behavioral therapy, with no role for the Epley's maneuver.
Question 9: Meniere's disease is characterized by which of the following pathophysiological changes?
- A. Perilymphatic hydrops
- B. Endolymphatic hydrops (Correct Answer)
- C. Otospongiosis
- D. Coalescent mastoiditis
Explanation: **Explanation:** **Meniere’s Disease (Endolymphatic Hydrops)** is a disorder of the inner ear characterized by an abnormal accumulation of endolymph within the membranous labyrinth. 1. **Why Option B is Correct:** The core pathophysiology involves either the **overproduction** or **under-absorption** of endolymph (specifically at the endolymphatic sac). This leads to increased hydrostatic pressure, causing distension of the membranous labyrinth—a state known as **Endolymphatic Hydrops**. This pressure causes periodic ruptures in Reissner’s membrane, allowing potassium-rich endolymph to mix with perilymph, resulting in the characteristic episodic vertigo and hearing loss. 2. **Why Other Options are Incorrect:** * **A. Perilymphatic hydrops:** This is not a recognized clinical entity in this context. Meniere’s specifically affects the endolymphatic compartment. * **C. Otospongiosis:** This refers to the early vascular stage of **Otosclerosis**, where mature lamellar bone is replaced by woven spongy bone, typically causing conductive hearing loss. * **D. Coalescent mastoiditis:** This is a complication of Acute Otitis Media (AOM) involving the destruction of bony septa between mastoid air cells. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad:** Episodic vertigo, fluctuating sensorineural hearing loss (SNHL), and tinnitus (often described as "roaring"). * **Audiometry:** Characteristically shows **low-frequency SNHL** in early stages (Rising curve). * **Lermoyez Syndrome:** A variant where hearing improves during a vertigo attack. * **Glycerol Test:** Used for diagnosis; glycerol acts as an osmotic diuretic, temporarily reducing hydrops and improving hearing. * **Management:** Medical (Salt restriction, Betahistine, Diuretics) or Surgical (Endolymphatic sac decompression for refractory cases).
Question 10: Which of the following is a true differential cause of referred otalgia?
- A. Carcinoma of the larynx
- B. Carcinoma of the oral cavity
- C. Carcinoma of the tongue
- D. All of the above (Correct Answer)
Explanation: **Explanation:** Referred otalgia occurs when pain is felt in the ear due to a shared nerve supply with a distant site of pathology. The ear receives sensory innervation from several cranial nerves (V, VII, IX, and X) and cervical nerves (C2, C3). Therefore, any lesion in the regions supplied by these nerves can present as ear pain. * **Carcinoma of the Larynx (Option A):** The larynx is supplied by the **Vagus nerve (CN X)** via the superior and recurrent laryngeal nerves. The ear is also supplied by the Vagus nerve via **Arnold’s nerve** (auricular branch). Malignancies of the supraglottis or hypopharynx frequently refer pain to the ear. * **Carcinoma of the Oral Cavity (Option B):** The anterior two-thirds of the tongue and the floor of the mouth are supplied by the **Mandibular nerve (V3)**. This shares a pathway with the **Auriculotemporal nerve**, which supplies the external auditory canal and TMJ. * **Carcinoma of the Tongue (Option C):** The posterior one-third of the tongue and the oropharynx are supplied by the **Glossopharyngeal nerve (CN IX)**. This nerve also provides sensation to the middle ear via **Jacobson’s nerve** (tympanic branch). This is a classic cause of referred otalgia in cases of tonsillitis or base-of-tongue tumors. **Clinical Pearls for NEET-PG:** * **The "Rule of 5":** Remember the nerves involved: CN V, VII, IX, X, and Cervical plexus (C2, C3). * **Trotter’s Triad:** Nasopharyngeal carcinoma can present with conductive hearing loss, palatal palsy, and referred otalgia (due to CN V involvement). * **High-Yield Fact:** In an elderly patient with a normal-looking ear exam complaining of otalgia, always perform a thorough fiberoptic laryngoscopy (FOL) to rule out an occult malignancy of the upper aerodigestive tract.
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