Acute Vestibulopathy — 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?
The investigation of choice for vestibular schwannoma is
All are true about vestibular neuritis EXCEPT:
In a patient with right vestibular neuronitis, what will be the finding on the head impulse test?
Following are the laboratory tests for the diagnosis of vestibular dysfunction except -
Which of the following associations is true regarding facial nerve palsy in temporal bone fractures?
All of the following are true about transverse fractures of the temporal bone EXCEPT:
A patient presents with facial nerve palsy following head trauma with fracture of the mastoid. What is the best intervention?
A patient with a sinus infection develops chemosis, bilateral proptosis, and fever. What is the most likely diagnosis?
Acute Vestibulopathy 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: The investigation of choice for vestibular schwannoma is
- A. Gadolinium enhanced MRI (Correct Answer)
- B. PET scan
- C. SPECT
- D. Contrast enhanced CT scan
Explanation: ***Gadolinium enhanced MRI*** - **Gadolinium-enhanced MRI** is the gold standard due to its superior spatial resolution for soft tissues, allowing for clear visualization of the tumor within the **internal auditory canal** and **cerebellopontine angle**. - It effectively detects even small **vestibular schwannomas**, which are typically missed by other imaging modalities. *PET scan* - **PET scans** are primarily used for assessing metabolic activity in tumors and are more relevant for distinguishing between benign and malignant lesions, or for staging cancer, rather than purely anatomical localization of a **vestibular schwannoma**. - Its resolution is often insufficient to precisely delineate small lesions in the **internal auditory canal**. *SPECT* - **SPECT** uses gamma-ray emitting radiotracers and is more commonly employed in nuclear medicine for functional imaging of organs or to assess blood flow, particularly in cardiac or neurological conditions like epilepsy, rather than for detailed anatomical imaging of tumors such as **vestibular schwannomas**. - Its spatial resolution is generally lower than MRI, making it less suitable for detecting small lesions in complex anatomical regions. *Contrast enhanced CT scan* - While a **contrast-enhanced CT scan** can show larger tumors and bony erosion, its soft tissue contrast is inferior to MRI, which means it may miss smaller **vestibular schwannomas**. - It also exposes the patient to **ionizing radiation**, and its primary role in vestibular schwannoma detection is often limited to cases where MRI is contraindicated.
Question 4: 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 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: 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: Which of the following associations is true regarding facial nerve palsy in temporal bone fractures?
- A. Common with longitudinal fractures
- B. Common with transverse fractures (Correct Answer)
- C. Always associated with CSF otorrhea
- D. Facial nerve injury is always complete
Explanation: **Explanation:** Temporal bone fractures are classically categorized based on their orientation relative to the long axis of the petrous part of the temporal bone. Understanding the anatomical path of the facial nerve is key to predicting injury patterns. * **Why Option B is Correct:** **Transverse fractures** (occurring perpendicular to the petrous ridge) are far more likely to involve the facial nerve. Although they account for only 20% of all temporal bone fractures, they result in facial nerve palsy in approximately **50% of cases**. This is because the fracture line often crosses the internal auditory canal or the fallopian canal directly. * **Why Option A is Incorrect:** **Longitudinal fractures** are the most common type (80%), but they involve the facial nerve in only about **15-20% of cases**. The injury here is usually due to edema or compression rather than direct transection. * **Why Option C is Incorrect:** While CSF otorrhea can occur in longitudinal fractures (due to tympanic membrane rupture), transverse fractures more commonly present with **CSF rhinorrhea** (as the CSF leaks through the Eustachian tube) or a hemotympanum with an intact drum. It is not an "always" association. * **Why Option D is Incorrect:** Facial nerve injury can be **incomplete (paresis)** or **complete (paralysis)**. In longitudinal fractures, the palsy is often delayed and incomplete, whereas in transverse fractures, it is more likely to be immediate and complete. **High-Yield Clinical Pearls for NEET-PG:** 1. **Most common site of injury:** The **Geniculate Ganglion** (Perigeniculate area) is the most frequent site of facial nerve injury in temporal bone trauma. 2. **Management:** Immediate-onset complete paralysis usually indicates nerve transection (requires surgical exploration); delayed-onset palsy suggests edema (managed conservatively with steroids). 3. **Hearing Loss:** Longitudinal fractures are associated with **conductive hearing loss** (ossicular disruption), while transverse fractures cause **sensorineural hearing loss** (labyrinthine involvement).
Question 8: All of the following are true about transverse fractures of the temporal bone EXCEPT:
- A. Facial nerve is commonly involved
- B. Sensorineural deafness can occur
- C. Conductive deafness can occur (Correct Answer)
- D. These fractures are less common
Explanation: Temporal bone fractures are traditionally classified into **Longitudinal** and **Transverse** based on their relationship to the long axis of the petrous pyramid. ### Why Option C is the Correct Answer (The "EXCEPT") Transverse fractures run perpendicular to the petrous ridge, typically crossing the internal auditory canal or the bony labyrinth (cochlea/vestibule). Because the fracture line directly destroys the inner ear structures or the vestibulocochlear nerve, it results in **Sensorineural Hearing Loss (SNHL)**. Conductive hearing loss is characteristic of *longitudinal* fractures, where the tympanic membrane or ossicular chain is disrupted, but the inner ear is spared. ### Analysis of Incorrect Options * **A. Facial nerve is commonly involved:** True. The facial nerve is injured in approximately **50%** of transverse fractures (compared to only 20% in longitudinal). The injury is often a complete transection. * **B. Sensorineural deafness can occur:** True. As the fracture line traverses the otic capsule, it causes permanent, often profound, SNHL and severe vertigo/nystagmus. * **D. These fractures are less common:** True. Transverse fractures account for only **20%** of temporal bone fractures, usually resulting from severe frontal or occipital blows. Longitudinal fractures are more common (80%). ### High-Yield Clinical Pearls for NEET-PG | Feature | Longitudinal Fracture (80%) | Transverse Fracture (20%) | | :--- | :--- | :--- | | **Mechanism** | Lateral blow (Temporal) | Frontal/Occipital blow | | **Hearing Loss** | **Conductive** (Common) | **Sensorineural** (Common) | | **Facial Nerve** | 20% (Delayed/Neuropraxia) | **50%** (Immediate/Transection) | | **Bleeding** | Bleeding from Ear (Tear in TM) | **Hemotympanum** (Intact TM) | | **CSF Leak** | CSF Otorrhea | CSF Rhinorrhea (via Eustachian tube) |
Question 9: A patient presents with facial nerve palsy following head trauma with fracture of the mastoid. What is the best intervention?
- A. Immediate decompression (Correct Answer)
- B. Wait and watch
- C. Facial sling
- D. Steroids
Explanation: **Explanation:** The management of post-traumatic facial nerve palsy depends primarily on the **onset** and **severity** of the paralysis. 1. **Why Option A is Correct:** In the context of head trauma (like a mastoid/temporal bone fracture), **immediate onset** of complete facial paralysis indicates a mechanical injury, such as nerve transection, compression by a bone spicule, or an intraneural hematoma. **Immediate surgical decompression** (and possible nerve repair/grafting) is the gold standard to prevent irreversible axonal degeneration and permanent fibrosis. 2. **Why Other Options are Incorrect:** * **Option B (Wait and Watch):** This is only appropriate for **delayed-onset** palsy (appearing days after trauma), which suggests secondary edema rather than physical disruption. * **Option C (Facial Sling):** This is a rehabilitative/static procedure used for long-standing, irreversible facial paralysis to improve symmetry; it is not an acute intervention. * **Option D (Steroids):** While steroids help reduce edema in delayed-onset palsy or Bell’s palsy, they cannot resolve a physical nerve compression or transection caused by a fracture. **High-Yield Clinical Pearls for NEET-PG:** * **Transverse Fractures:** More commonly associated with facial nerve injury (50%) and sensorineural hearing loss. * **Longitudinal Fractures:** More common overall (80%), but less frequently involve the facial nerve (20%). * **Most common site of injury:** The **perigeniculate ganglion** area is the most frequent site of facial nerve trauma in temporal bone fractures. * **Diagnostic Rule:** If Schirmer’s test is abnormal, the lesion is at or proximal to the geniculate ganglion.
Question 10: A patient with a sinus infection develops chemosis, bilateral proptosis, and fever. What is the most likely diagnosis?
- A. Lateral sinus thrombosis
- B. Frontal lobe abscess
- C. Cavernous sinus thrombosis (Correct Answer)
- D. Meningitis
Explanation: **Explanation:** The clinical triad of **chemosis (conjunctival edema), bilateral proptosis, and fever** following a sinus infection is the classic presentation of **Cavernous Sinus Thrombosis (CST)**. **1. Why Cavernous Sinus Thrombosis is correct:** The cavernous sinuses are paired venous structures located on either side of the sella turcica. They receive venous drainage from the face (via the ophthalmic veins) and the paranasal sinuses (ethmoid and sphenoid). An infection in these areas can lead to septic thrombosis. * **Proptosis and Chemosis:** Occur due to impaired venous drainage from the orbit. * **Bilateral Involvement:** This is the hallmark of CST. Because the two cavernous sinuses communicate via the intercavernous sinuses, an infection starting on one side rapidly spreads to the other. **2. Why other options are incorrect:** * **Lateral Sinus Thrombosis:** Usually a complication of chronic suppurative otitis media (CSOM). It presents with "Griesinger's sign" (edema over the mastoid) and a "picket-fence" fever, but not proptosis or chemosis. * **Frontal Lobe Abscess:** Presents with features of raised intracranial pressure (headache, vomiting, papilledema) and altered mental status, but lacks the specific orbital signs seen here. * **Meningitis:** Presents with fever, neck stiffness, and photophobia. While it can coexist with CST, it does not explain the mechanical orbital findings (proptosis). **Clinical Pearls for NEET-PG:** * **Nerves involved:** Cranial nerves III, IV, V1, V2, and VI pass through the cavernous sinus. **CN VI (Abducens)** is usually the first to be affected (lateral rectus palsy). * **Danger area of the face:** Infections here (e.g., furuncles) can lead to CST due to the **valveless** nature of the facial and ophthalmic veins. * **Treatment:** High-dose intravenous antibiotics and management of the primary source (sinus drainage).
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