Vestibular Neuritis — MCQs
A 25-year-old woman presents with episodes of dizziness, tinnitus, and hearing loss in the right ear. What is the most likely diagnosis?
Vestibular evoked myogenic potential (VEMP) is a tool for evaluating which of the following?
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?
In a patient with right vestibular neuronitis, what will be the finding on the head impulse test?
All are true about vestibular neuritis EXCEPT:
A 72-year-old man presents to his primary care physician with progressively worsening hearing loss. He states that his trouble with hearing began approximately 7-8 years ago. He is able to hear when someone is speaking to him; however, he has difficulty with understanding what is being said, especially when there is background noise. In addition to his current symptoms, he reports a steady ringing in both ears, and at times experiences dizziness. Medical history is significant for three prior episodes of acute otitis media. Family history is notable for his father being diagnosed with cholesteatoma. His temperature is 98.6°F (37°C), blood pressure is 138/88 mmHg, pulse is 74/min, and respirations are 13/min. On physical exam, when a tuning fork is placed in the middle of the patient's forehead, sound is appreciated equally on both ears. When a tuning fork is placed by the external auditory canal and subsequently on the mastoid process, air conduction is greater than bone conduction. Which of the following is most likely the cause of this patient's symptoms?
Best investigation to identify the cause of sudden onset unilateral vertigo, tinnitus, and hearing loss?
Meniere's disease is characterized by which triad of symptoms?
Dehiscence in the external auditory canal causes infection in the parotid gland via which anatomical structure?
A false positive fistula test is associated with which of the following conditions?
Vestibular Neuritis Indian Medical PG Practice Questions and MCQs
Question 1: A 25-year-old woman presents with episodes of dizziness, tinnitus, and hearing loss in the right ear. What is the most likely diagnosis?
- A. Labyrinthitis
- B. Ménière's disease (Correct Answer)
- C. Acoustic neuroma
- D. Benign paroxysmal positional vertigo
Explanation: ***Ménière's disease*** - This condition is characterized by a classic triad of **episodic vertigo (dizziness)**, fluctuating **sensorineural hearing loss**, and **tinnitus**, often accompanied by aural fullness, typically affecting one ear. - The symptoms arise from an accumulation of **endolymph** in the inner ear, leading to increased pressure and dysfunction. *Labyrinthitis* - **Labyrinthitis** is an inflammation of the inner ear, usually viral, causing sudden, severe **vertigo** potentially with hearing loss and tinnitus. - Unlike Meniere's disease, **hearing loss** and **tinnitus** in labyrinthitis are usually constant rather than episodic or fluctuating. *Acoustic neuroma* - An **acoustic neuroma** (vestibular schwannoma) is a benign tumor on the eighth cranial nerve, often causing **gradual, progressive unilateral hearing loss**, tinnitus, and **balance issues**, but typically not episodic severe dizziness. - While it can cause hearing loss and tinnitus, the **episodic nature of vertigo** is less common than in Ménière's disease. *Benign paroxysmal positional vertigo* - **BPPV** is characterized by sudden, **brief episodes of vertigo** triggered by specific head movements, caused by dislodged **otoconia** in the semicircular canals. - Critically, BPPV does **not** typically cause associated **hearing loss or tinnitus**, which are prominent symptoms in the presented case.
Question 2: Vestibular evoked myogenic potential (VEMP) is a tool for evaluating which of the following?
- A. Superior vestibular nerve disorders
- B. Cochlear nerve lesions
- C. Auditory nerve function
- D. Inferior vestibular nerve disorders (Correct Answer)
Explanation: ***Inferior vestibular nerve disorders*** - **VEMP** uses **loud acoustic stimuli** or **bone vibration** to activate the **saccule**, with the response pathway: saccule → inferior vestibular nerve → vestibular nucleus → vestibulospinal tract → muscle response. - **Cervical VEMP (cVEMP)** is recorded from the **sternocleidomastoid muscle**, while **ocular VEMP (oVEMP)** is recorded from **extraocular muscles**; absent or delayed responses indicate **saccular or inferior vestibular nerve dysfunction**. *Superior vestibular nerve disorders* - The **superior vestibular nerve** innervates the **utricle** and **semicircular canals**, which are assessed by **head impulse test** and **caloric testing**, not VEMP. - **VEMP** is the only clinical test specifically assessing **otolith (saccule) function** and does not evaluate semicircular canal pathways. *Cochlear nerve lesions* - **Cochlear nerve** assessment requires **pure tone audiometry**, **auditory brainstem response (ABR)**, and **otoacoustic emissions**. - **VEMP** evaluates vestibular pathways through **muscle reflexes**, not auditory nerve conduction or cochlear function. *Auditory nerve function* - **VEMP** is a vestibular test that evaluates **otolith organs** and their neural pathways, not auditory function. - While VEMP uses **acoustic stimuli** to trigger the response, it measures **vestibulospinal or vestibulo-ocular reflexes**, not hearing or auditory nerve conduction.
Question 3: 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 4: 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 5: 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 6: A 72-year-old man presents to his primary care physician with progressively worsening hearing loss. He states that his trouble with hearing began approximately 7-8 years ago. He is able to hear when someone is speaking to him; however, he has difficulty with understanding what is being said, especially when there is background noise. In addition to his current symptoms, he reports a steady ringing in both ears, and at times experiences dizziness. Medical history is significant for three prior episodes of acute otitis media. Family history is notable for his father being diagnosed with cholesteatoma. His temperature is 98.6°F (37°C), blood pressure is 138/88 mmHg, pulse is 74/min, and respirations are 13/min. On physical exam, when a tuning fork is placed in the middle of the patient's forehead, sound is appreciated equally on both ears. When a tuning fork is placed by the external auditory canal and subsequently on the mastoid process, air conduction is greater than bone conduction. Which of the following is most likely the cause of this patient's symptoms?
- A. Stapedial abnormal bone growth
- B. Endolymphatic hydrops
- C. Cochlear hair cell degeneration (Correct Answer)
- D. Accumulation of desquamated keratin debris
Explanation: ***Cochlear hair cell degeneration*** - The patient's **progressive, bilateral hearing loss** over several years, difficulty understanding speech in noise, and **tinnitus** are classic symptoms of **presbycusis**, which results from age-related **degeneration of cochlear hair cells**. - The **normal Weber test** (no lateralization) and **Rinne test** (air conduction > bone conduction) indicate a **sensorineural hearing loss**, consistent with cochlear pathology rather than conductive issues. *Stapedial abnormal bone growth* - This condition (**otosclerosis**) causes **conductive hearing loss** due to fixation of the stapes, which would present with an **abnormal Rinne test** (bone conduction > air conduction) in the affected ear. - While it can cause progressive hearing loss and tinnitus, the normal Rinne test contradicts this diagnosis. *Endolymphatic hydrops* - This is the underlying pathology of **Ménière's disease**, which typically presents with episodic vertigo, fluctuating sensorineural hearing loss, tinnitus, and aural fullness. - The patient's dizziness is non-episodic, and the absence of fluctuating hearing loss and aural fullness makes Ménière's less likely. *Accumulation of desquamated keratin debris* - This describes a **cholesteatoma**, which typically causes **conductive hearing loss** and often presents with otorrhea, earache, and possibly vestibular symptoms. - The normal Rinne test (indicating sensorineural loss) and lack of otorrhea or earache make cholesteatoma unlikely, despite a family history.
Question 7: Best investigation to identify the cause of sudden onset unilateral vertigo, tinnitus, and hearing loss?
- A. CT scan
- B. Tympanometry
- C. MRI (Correct Answer)
- D. Audiometry
Explanation: ***MRI*** - **MRI** is the best investigation for **sudden onset vertigo, tinnitus, and hearing loss** because it can identify serious central and peripheral causes such as **acoustic neuroma**, **labyrinthine infarction**, or **demyelinating disease**. - This symptom triad, particularly if unilateral and acute, warrants investigation for **retrocochlear pathology** and **posterior circulation stroke**, which MRI with contrast (IAM protocol) is excellent at visualizing. - While **audiometry is typically performed first** to document the hearing loss, **MRI is the definitive investigation** to identify the underlying structural cause. *CT scan* - A **CT scan** is not the investigation of choice for this symptom complex as it has **poor soft tissue resolution** for the inner ear, internal acoustic meatus, and brainstem. - While CT can identify bony abnormalities and is useful in trauma, it is **unsuitable for detecting lesions** like acoustic neuromas, labyrinthitis, or demyelinating plaques that might cause these symptoms. *Tympanometry* - **Tympanometry** assesses **middle ear function** and would be useful for conditions like otitis media with effusion or ossicular chain discontinuity, which cause **conductive hearing loss**. - It would **not evaluate the inner ear structures** or central nervous system, making it inadequate for investigating sudden sensorineural hearing loss with vertigo. *Audiometry* - **Audiometry (Pure Tone Audiometry)** is essential to **confirm and characterize the hearing loss** (sensorineural vs conductive) and is typically performed early in the workup. - However, it is a **functional test** that documents hearing thresholds but **does not image the underlying pathology**, which is crucial for identifying the cause of this acute presentation.
Question 8: Meniere's disease is characterized by which triad of symptoms?
- A. Conductive hearing loss and tinnitus
- B. Vertigo, ear discharge, tinnitus, and headache
- C. Vertigo, tinnitus, hearing loss, and headache
- D. Vertigo, tinnitus, and hearing loss (Correct Answer)
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. The classic clinical triad consists of: 1. **Episodic Vertigo:** Sudden, rotatory vertigo lasting 20 minutes to several hours, often accompanied by nausea and vomiting. 2. **Sensorineural Hearing Loss (SNHL):** Characteristically fluctuating and low-frequency in the early stages. 3. **Tinnitus:** Often described as a low-pitched "roaring" or "seashell" sound. *(Note: Many authorities include a fourth symptom—**Aural Fullness**—making it a tetrad).* **Analysis of Options:** * **Option A:** Incorrect. Meniere’s causes **Sensorineural** hearing loss, not conductive. Conductive loss suggests pathology in the external or middle ear (e.g., ASOM, Otosclerosis). * **Option B:** Incorrect. **Ear discharge (Otorrhea)** is a hallmark of middle ear infections (CSOM) and is never seen in Meniere’s, which is an inner ear pathology with an intact tympanic membrane. * **Option C:** Incorrect. While headache can occur, it is not a defining component of the diagnostic triad. Its presence might instead suggest Vestibular Migraine. * **Option D:** **Correct.** This captures the classic diagnostic triad essential for NEET-PG. **Clinical Pearls for NEET-PG:** * **Pathology:** Distension of the endolymphatic system (Reissner’s membrane bulges into the scala vestibuli). * **Lermoyez Syndrome:** A variant where hearing improves during a vertigo attack ("the phenomenon of reverse symptoms"). * **Tuning Fork Tests:** Rinne positive (SNHL) and Weber lateralized to the better ear. * **Audiometry:** Shows a "rising curve" in early stages (low-frequency loss). * **Glycerol Test:** Used for diagnosis; oral glycerol (osmotic diuretic) temporarily improves hearing by reducing endolymphatic pressure. * **Management:** Low salt diet, Betahistine (drug of choice), and diuretics. Intratympanic Gentamicin is used for refractory cases.
Question 9: Dehiscence in the external auditory canal causes infection in the parotid gland via which anatomical structure?
- A. Fissure of Santorini (Correct Answer)
- B. Notch of Rivinus
- C. Petro-tympanic fissure
- D. Retropharyngeal fissure
Explanation: ### Explanation The correct answer is **A. Fissure of Santorini**. **1. Why Fissure of Santorini is correct:** The external auditory canal (EAC) consists of an outer cartilaginous part and an inner bony part. The **Fissures of Santorini** are vertical deficiencies or dehiscent gaps found in the anterior wall of the **cartilaginous** portion of the EAC. These fissures provide a direct anatomical pathway for infections or neoplasms to spread between the EAC and the **parotid gland** or the infratemporal fossa. Clinically, this is the route through which malignant otitis externa spreads to the parotid. **2. Why the other options are incorrect:** * **B. Notch of Rivinus:** This is a deficiency in the superior part of the **tympanic sulcus** (bony annulus). It is the site where the pars flaccida (Shrapnell’s membrane) attaches. It does not communicate with the parotid gland. * **C. Petro-tympanic fissure (Glaserian fissure):** This is a slit in the temporal bone that houses the chorda tympani nerve and the anterior tympanic artery. It opens into the infratemporal fossa near the TMJ, not the parotid gland. * **D. Retropharyngeal fissure:** This is not a standard anatomical structure of the EAC. The retropharyngeal space is located behind the pharynx and is separated from the ear by the carotid sheath and parapharyngeal space. **3. High-Yield Clinical Pearls for NEET-PG:** * **Foramen of Huschke:** This is a deficiency in the antero-inferior part of the **bony** EAC (present in children, usually closes by age 5). If persistent, it can also allow communication between the EAC and the parotid/TMJ. * **Malignant Otitis Externa:** Always remember that the spread of this "malignancy" (actually an osteomyelitis) to the parotid occurs via the Fissures of Santorini. * **Tragal sign:** Pain on pressing the tragus suggests an infection in the cartilaginous EAC (furuncle), often involving these anatomical planes.
Question 10: A false positive fistula test is associated with which of the following conditions?
- A. Perilymph fistula
- B. Malignant sclerosis
- C. Congenital syphilis (Correct Answer)
- D. Cholesteatoma
Explanation: **Explanation:** The **Fistula Test** is used to identify an abnormal communication (fistula) between the inner and middle ear. A positive result occurs when pressure changes in the external auditory canal (via a Siegle’s speculum) induce nystagmus and vertigo. **1. Why Congenital Syphilis is correct:** In **Congenital Syphilis**, a "False Positive" fistula test occurs, also known as **Hennebert’s Sign**. It is considered "false" because there is no actual bony fistula present. Instead, the nystagmus is caused by: * **Fibrous adhesions** between the stapes footplate and the membranous labyrinth. * An abnormally **hypermobile stapes** footplate. Pressure is transmitted directly to the saccule, triggering the vestibular response despite an intact bony labyrinth. **2. Analysis of Incorrect Options:** * **Perilymph Fistula:** This is a **True Positive**. There is an actual breach in the oval or round window membrane, allowing pressure to affect the perilymph. * **Cholesteatoma:** This is the most common cause of a **True Positive** fistula test, typically due to erosion of the **Horizontal Semicircular Canal**. * **Malignant Sclerosis:** This is not a standard clinical term related to fistula testing. (Otosclerosis, however, usually results in a negative test unless complicated by other factors). **3. NEET-PG High-Yield Pearls:** * **Hennebert’s Sign:** Specifically refers to the false-positive fistula test in Congenital Syphilis or Meniere’s disease (due to fibrosis). * **Tullio Phenomenon:** Vertigo/nystagmus induced by **loud sounds**. Seen in Congenital Syphilis, Meniere’s, and Superior Semicircular Canal Dehiscence (SSCD). * **False Negative Test:** Occurs if the fistula is plugged by cholesteatoma/granulations or if the labyrinth is "dead" (non-functional).
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