Vestibular Testing — MCQs
Hallpike test is done for
Cervical Vestibular Evoked Myogenic Potential (cVEMP) detects lesion of -
Which of the following test is being performed on the patient?
A patient with cholesteatoma has lateral semicircular canal fistula. The most specific sign is:
All are true about vestibular neuritis EXCEPT:
Following are the laboratory tests for the diagnosis of vestibular dysfunction except -
A false positive fistula test is associated with which of the following conditions?
A 10-year-old boy presented with sensorineural deafness not benefited with a hearing aid. What is the next treatment?
A glomus tumor is invading the visceral part of the carotid canal. It is classified as which type?
Common presenting manifestations of Meniere's disease are all except?
Vestibular Testing Indian Medical PG Practice Questions and MCQs
Question 1: Hallpike test is done for
- A. Vestibular function (Correct Answer)
- B. Cochlear function
- C. Audiometry
- D. Eustachian tube function
Explanation: ***Vestibular function*** - The **Dix-Hallpike maneuver** is a diagnostic test used to identify **benign paroxysmal positional vertigo (BPPV)**, a disorder of the vestibular system. - It involves specific head and body movements to provoke dizziness and **nystagmus**, indicating otolith displacement in the semicircular canals. *Cochlear function* - **Cochlear function** relates to hearing, which is evaluated by tests like **audiometry** or **otoacoustic emissions**. - The Hallpike test does not assess the ability to perceive sound or the health of the cochlea. *Audiometry* - **Audiometry** is a hearing test that measures a person's ability to hear sounds at different frequencies and intensities, assessing the **degree and type of hearing loss**. - It is unrelated to assessing vertigo or balance disorders caused by semicircular canal pathology. *Eustachian tube function* - **Eustachian tube function** is assessed by tests like **tympanometry** or the **Valsalva maneuver**, which evaluate middle ear pressure equalization. - The Hallpike test does not assess Eustachian tube patency or function.
Question 2: Cervical Vestibular Evoked Myogenic Potential (cVEMP) detects lesion of -
- A. Inferior Vestibular Nerve (Correct Answer)
- B. Cochlear Nerve
- C. Facial Nerve
- D. Superior Vestibular Nerve
Explanation: ***Inferior Vestibular Nerve*** - **cVEMP** primarily assesses the function of the **saccule** and its neural pathway via the **inferior vestibular nerve (IVN)**. - The saccule is sensitive to **vertical head movements and linear acceleration** and transmits signals through the IVN to the vestibulospinal pathway. - cVEMP is recorded from the **sternocleidomastoid muscle** and reflects the **vestibulocollic reflex**. *Cochlear Nerve* - The **cochlear nerve** is responsible for **auditory processing** and is assessed by tests like audiometry and ABR, not VEMPs. - While it's part of the vestibulocochlear nerve (CN VIII), its function is distinct from vestibular assessment. *Facial Nerve* - The **facial nerve (CN VII)** controls **facial muscles** and taste sensation, with no direct role in vestibular function. - Lesions are detected through facial movement assessment and electrophysiological tests like electroneuronography (ENoG). *Superior Vestibular Nerve* - The **superior vestibular nerve (SVN)** primarily innervates the **anterior and horizontal semicircular canals** and the **utricle**. - Its function is assessed by **oVEMP (ocular VEMP)**, **caloric reflex test**, or **head impulse test**, rather than cVEMP.
Question 3: Which of the following test is being performed on the patient?
- A. Caloric stimulation test
- B. Doll's eye reflex
- C. Dix-Hallpike test (Correct Answer)
- D. Frenzel maneuver
Explanation: ***Dix-Hallpike test*** - The image depicts a patient being moved from an upright sitting position to a supine position with the head turned to one side and extended, which is characteristic of the **Dix-Hallpike maneuver**. - This test is used to diagnose **benign paroxysmal positional vertigo (BPPV)** by provoking vertigo and nystagmus as a result of otoconia displacement in the semicircular canals. *Caloric stimulation test* - This test involves introducing **warm or cold water/air into the ear canal** to induce nystagmus, assessing the vestibular system. - It's typically performed with the patient lying supine with their head elevated at 30 degrees, not involving the specific positional changes shown in the image. *Doll's eye reflex* - Also known as the **oculocephalic reflex**, it assesses brainstem function by rapidly turning the patient's head while observing eye movement. - This reflex is primarily used to evaluate comatose patients and does not involve the complex body and head positioning seen in the image. *Frenzel maneuver* - The Frenzel maneuver is performed during **otoscopy** to check for nystagmus by having the patient gaze through high plus lenses in a dark room. - It is often used to suppress visual fixation and enhance nystagmus, but it does not involve the specific body or head movements depicted.
Question 4: A patient with cholesteatoma has lateral semicircular canal fistula. The most specific sign is:
- A. Head thrust test
- B. Fistula test (Correct Answer)
- C. Hennebert's sign
- D. Dix-Hallpike test
Explanation: ***Fistula test*** - The **fistula test** (Positive pressure test or Hennebert's test) directly assesses for a communication between the middle ear and the labyrinth by applying positive or negative pressure to the external auditory canal. - A positive result, indicated by **nystagmus** or **vertigo** induced by pressure changes, is the **most specific sign** for a **labyrinthine fistula** in the context of **cholesteatoma**. - The lateral semicircular canal is the most commonly affected site in cholesteatoma-related fistulae. *Hennebert's sign* - **Hennebert's sign** refers to **nystagmus** or **vertigo** induced by pressure changes in the external auditory canal **in the absence of an actual fistula**. - It represents a **false positive fistula test** and is classically associated with **congenital syphilis**, **Meniere's disease**, or other conditions causing increased labyrinthine membrane mobility. - In this case with a **confirmed fistula**, the positive pressure test would be called a **positive fistula test**, not Hennebert's sign. *Head thrust test* - The **head thrust test** evaluates the function of the **vestibulo-ocular reflex (VOR)** and is used to detect **peripheral vestibular hypofunction**. - While cholesteatoma can affect vestibular function, this test is **not specific** for identifying a **labyrinthine fistula**. *Dix-Hallpike test* - The **Dix-Hallpike test** is used to diagnose **Benign Paroxysmal Positional Vertigo (BPPV)** by identifying nystagmus and vertigo triggered by specific head positions. - This test detects **otoconia displacement** in the semicircular canals and is **not relevant** for identifying a **labyrinthine fistula**.
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: Following are the laboratory tests for the diagnosis of vestibular dysfunction except -
- A. Galvanic test
- B. Electronystagmography
- C. Gelle's test (Correct Answer)
- D. Optokinetic test
Explanation: ***Gelle's test*** - **Gelle's test** is used to evaluate the mobility of the **tympanic membrane** and the integrity of the **ossicular chain**, primarily in the diagnosis of **otosclerosis**. - It does not directly assess the function of the **vestibular system** or its pathways. *Galvanic test* - The Galvanic test involves applying an electrical current to the mastoid process to stimulate the **vestibular nerve** directly. - It assesses the function of the **semicircular canals** and their connections to the brainstem. *Electronystagmography* - **Electronystagmography (ENG)** records eye movements during various maneuvers to evaluate the function of the **vestibular-ocular reflex (VOR)**. - It helps detect nystagmus and other eye movement abnormalities indicative of **vestibular dysfunction**. *Optokinetic test* - The **optokinetic test** assesses the ability of the eyes to follow moving targets, evaluating the **central vestibular pathways** and their interaction with the visual system. - It can help differentiate between peripheral and central **vestibular disorders**.
Question 7: 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).
Question 8: A 10-year-old boy presented with sensorineural deafness not benefited with a hearing aid. What is the next treatment?
- A. Cochlear implant (Correct Answer)
- B. Fenestromy
- C. Stapedectomy
- D. Stapes fixation
Explanation: **Explanation:** The patient is a 10-year-old child with **Sensorineural Hearing Loss (SNHL)** who has failed to benefit from conventional hearing aids. In cases of severe-to-profound SNHL where the auditory nerve is intact but the hair cells in the cochlea are non-functional, a **Cochlear Implant** is the gold standard treatment. It bypasses the damaged hair cells and directly stimulates the auditory nerve fibers electrically. **Analysis of Options:** * **A. Cochlear Implant (Correct):** Indicated for bilateral severe-to-profound SNHL when hearing aids provide inadequate benefit. In children, early implantation is crucial for speech and language development. * **B. Fenestromy:** This is an obsolete surgical procedure formerly used for otosclerosis (conductive hearing loss) to create a new window in the labyrinth. It has no role in treating SNHL. * **C. Stapedectomy:** This is the treatment of choice for **Otosclerosis**, which presents as **Conductive Hearing Loss (CHL)** due to stapes fixation. It involves replacing the stapes with a prosthesis and is contraindicated in SNHL. * **D. Stapes Fixation:** This is a pathological condition (clinical finding in otosclerosis), not a treatment modality. **High-Yield Clinical Pearls for NEET-PG:** * **Ideal Age for Implantation:** The earlier, the better (usually >12 months) to utilize the brain's neuroplasticity for language acquisition. * **Prerequisite:** A patent cochlea and a functional **Cochlear Nerve (CN VIII)** must be present (confirmed via MRI). * **Auditory Brainstem Implant (ABI):** Indicated if the cochlear nerve is absent or destroyed (e.g., Bilateral Acoustic Neuroma/NF2). * **Hennebert’s Sign:** False positive fistula test seen in Meniere’s or Congenital Syphilis; do not confuse with surgical indications.
Question 9: A glomus tumor is invading the visceral part of the carotid canal. It is classified as which type?
- A. Type B
- B. Type C1
- C. Type C2 (Correct Answer)
- D. Type C3
Explanation: This question tests your knowledge of the **Fisch Classification** for Glomus tumors (Paragangliomas), which is the gold standard for determining surgical approach based on anatomical extension. ### **Explanation of the Correct Answer** The Fisch classification categorizes tumors based on their involvement of the temporal bone and skull base. **Type C** tumors specifically involve the **infralabyrinthine compartment** and extend along the **carotid canal**. * **Type C1:** Destroys the bone of the carotid foramen but does not involve the carotid artery itself. * **Type C2:** Invades the **vertical (visceral) portion** of the carotid canal. * **Type C3:** Extends along the **horizontal portion** of the carotid canal. Since the question specifies invasion of the visceral (vertical) part of the carotid canal, **Type C2** is the correct classification. ### **Analysis of Incorrect Options** * **Type B:** These tumors are limited to the tympanomastoid area without involvement of the infralabyrinthine compartment or the carotid canal. * **Type C1:** This involves only the entrance (foramen) of the carotid canal, not the canal's vertical segment. * **Type D:** These tumors have **intracranial extension**. D1 involves extension <2cm, while D2 involves extension >2cm. ### **Clinical Pearls for NEET-PG** * **Glomus Jugulare:** Arises from the dome of the jugular bulb (Fisch Type C/D). * **Glomus Tympanicum:** Arises from the promontory (Fisch Type A). * **Phelp’s Sign:** Loss of the bony plate between the carotid canal and the jugular foramen on CT (indicative of Glomus Jugulare). * **Brown’s Sign:** Pulsatile blanching of the tympanic membrane on positive pressure with a Siegel’s speculum (Pathognomonic). * **Aquino’s Sign:** Blanching of the mass on carotid artery compression.
Question 10: Common presenting manifestations of Meniere's disease are all except?
- A. Tinnitus
- B. Vertigo
- C. Sensorineural deafness
- D. Loss of consciousness (Correct Answer)
Explanation: **Explanation:** Meniere’s disease (Endolymphatic Hydrops) is a disorder of the inner ear characterized by an increase in the volume of endolymph. The classic presentation involves a specific **diagnostic triad** of symptoms. **Why "Loss of Consciousness" is the correct answer:** Meniere’s disease affects the peripheral vestibular system and the cochlea. While the vertigo can be severe enough to cause a "drop attack" (Tumarkin’s otolithic crisis) where the patient falls suddenly without warning, **consciousness is always preserved.** Loss of consciousness (syncope) suggests a central nervous system pathology or a cardiovascular issue, rather than a peripheral inner ear disorder. **Analysis of other options:** * **Vertigo (Option B):** Episodic, true objective vertigo is a hallmark. Attacks typically last 20 minutes to several hours and are often accompanied by nausea and vomiting. * **Sensorineural Deafness (Option C):** Characteristically **fluctuating** and **low-frequency** SNHL. In early stages, hearing returns to normal between attacks, but eventually becomes permanent. * **Tinnitus (Option A):** Usually low-pitched and described as "roaring" or "seashell" sound. It often worsens during acute attacks. **High-Yield Clinical Pearls for NEET-PG:** * **Pathology:** Distension of the endolymphatic system (Endolymphatic Hydrops), most commonly affecting the **scala media** and saccule. * **Audiometry:** Shows low-frequency SNHL; **Recruitment phenomenon** is positive (indicates cochlear pathology). * **Glycerol Test:** Used for diagnosis; oral glycerol (osmotic diuretic) temporarily improves hearing by reducing endolymphatic pressure. * **Management:** Low salt diet, diuretics (Acetazolamide), and Betahistine for maintenance; Intratympanic Gentamicin or Labyrinthectomy for refractory cases.
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