Vestibular Disorders — MCQs

Vestibular Disorders Indian Medical PG Practice Questions and MCQs

Question 51: A patient presents with vertigo, tinnitus, and head tilt. He underwent myringoplasty for the safe type of chronic suppurative otitis media (CSOM) 6 months back. What is your diagnosis?

A. Paget disease
B. Labyrinthitis
C. Vestibular schwannoma
D. Perilymphatic fistula (Correct Answer)

Explanation: ***Perilymphatic fistula*** - The combination of **vertigo**, **tinnitus**, and **head tilt** occurring after a **myringoplasty**, even for a safe type of CSOM, suggests a perilymphatic fistula. - Myringoplasty can occasionally involve trauma to the **oval or round window**, leading to a direct communication between the inner ear (perilymph) and the middle ear, causing these symptoms. *Paget disease* - This is a **bone remodeling disorder** that primarily affects the skull, pelvis, and long bones, leading to bone pain and deformities. - While it can cause hearing loss (due to otosclerosis) and a sense of imbalance, it does not typically present with the acute onset of **vertigo** and **tinnitus** following ear surgery. *Labyrinthitis* - **Labyrinthitis** is an inflammation of the inner ear, typically caused by a viral infection, leading to sudden, severe **vertigo**, **nausea**, and often **hearing loss** or **tinnitus**. - While the symptoms of vertigo and tinnitus are present, the history of recent myringoplasty makes a **structural compromise** like a perilymphatic fistula a more specific diagnosis than generalized inflammation. *Vestibular schwannoma* - Also known as an acoustic neuroma, this is a **benign tumor** on the eighth cranial nerve, causing **gradual unilateral hearing loss**, **tinnitus**, and **imbalance**, but rarely sudden, intense vertigo unless very large. - The presentation with a history of myringoplasty and acute symptoms makes a **spontaneous structural defect** more likely than a slowly growing tumor.

Question 52: All the following are true about Meniere's disease except?

A. Low frequency hearing loss
B. Increase in endolymph
C. Idiopathic
D. Destroying the cochlea is mandatory (Correct Answer)

Explanation: ***Destroying the cochlea is mandatory*** - While various interventions, including **destructive procedures**, exist for Meniere's disease in severe cases refractory to medical therapy (e.g., labyrinthectomy, vestibular neurectomy), it is **not mandatory** for diagnosis or initial management. - Initial management typically involves **conservative medical treatment** to control symptoms, such as **diuretics**, low-salt diet, and symptomatic relief during attacks. *Low frequency hearing loss* - Meniere's disease typically presents with **fluctuating sensorineural hearing loss**, predominantly affecting **low frequencies** in the early stages. - This characteristic hearing loss is often associated with aural fullness and tinnitus. *Increase in endolymph* - The underlying pathology of Meniere's disease is believed to be **endolymphatic hydrops**, which is an **excessive accumulation of endolymph** in the inner ear. - This increased pressure within the endolymphatic system distorts the membranous labyrinth, leading to the classic symptoms. *Idiopathic* - Meniere's disease is generally considered **idiopathic**, meaning its specific cause is unknown. - While various theories exist regarding its etiology (e.g., viral infections, autoimmune disorders, vascular compromise), a definitive cause has not been identified.

Question 53: All of the following are seen in Meniere's Disease except:

A. Fullness of ear
B. Ear Pain (Correct Answer)
C. Vertigo
D. Tinnitus

Explanation: ***Ear Pain*** - **Otalgia** (ear pain) is not a typical symptom of **Meniere's disease**. - While patients may experience discomfort due to pressure, sharp or significant pain is generally absent. *Fullness of ear* - A sensation of **aural fullness** or pressure in the affected ear is a characteristic symptom of Meniere's disease, often preceding a vertiginous attack. - This symptom is thought to be due to the buildup of **endolymphatic fluid** within the inner ear. *Vertigo* - **Episodic rotational vertigo** is a hallmark symptom of Meniere's disease, significantly impacting daily activities and often accompanied by nausea and vomiting. - These attacks are typically sudden, severe, and can last from 20 minutes to several hours. *Tinnitus* - **Tinnitus**, often described as a ringing, buzzing, or roaring sound, is a common symptom in patients with Meniere's disease. - It usually fluctuates in intensity and can worsen before or during a vertigo attack.

Question 54: Acronym "COWS" is used for?

A. Bithermal caloric test (Correct Answer)
B. Fistula test
C. Kobrak test
D. Cold-air caloric test

Explanation: ***Bithermal caloric test*** - The acronym **COWS** stands for **C**old **O**pposite, **W**arm **S**ame, a mnemonic used to remember the direction of **nystagmus** induced during the **bithermal caloric test**. - This test assesses the function of the **horizontal semicircular canal** and its central connections by introducing warm or cold water into the ear canal. *Fistula test* - The fistula test is used to detect a **perilymph fistula** by observing nystagmus or vertigo in response to pressure changes in the external auditory canal. - It does not involve the COWS mnemonic or the caloric stimulation of the labyrinth. *Kobrak test* - The **Kobrak test** is a modified caloric test using ice water to elicit nystagmus, primarily performed when standard caloric testing yields no response. - While it is a type of caloric test, the COWS mnemonic is specifically associated with the results and interpretation of the **bithermal caloric test**. *Cold-air caloric test* - The **cold-air caloric test** uses cold air instead of water to stimulate the labyrinth, often preferred when water irrigation is contraindicated. - Although it is a caloric test, the **COWS mnemonic** is specifically developed for the **bithermal caloric test**'s interpretation where both warm and cold stimuli are compared for directional response.

Question 55: Dix-Hallpike maneuver is used to assess-

A. Ear Ossicle continuity
B. Cochlear function
C. Brainstem function
D. Vestibular function (Correct Answer)

Explanation: ***Vestibular function*** - The Dix-Hallpike maneuver is a diagnostic test performed to identify **benign paroxysmal positional vertigo (BPPV)**. - It assesses the integrity of the **posterior semicircular canal** within the vestibular system by provoking nystagmus and vertigo. *Ear Ossicle continuity* - This is typically assessed through **tympanometry** and **audiometric testing**, not through a positional maneuver. - Problems with ossicular continuity lead to conductive hearing loss, not usually positional vertigo. *Cochlear function* - **Cochlear function** relates to hearing and is assessed using tests like **audiometry** and **otoacoustic emissions**. - The Dix-Hallpike maneuver does not evaluate the auditory function of the inner ear. *Brainstem function* - **Brainstem function** is evaluated by assessing cranial nerve reflexes, motor and sensory pathways, and level of consciousness. - While vestibular pathways involve the brainstem, the Dix-Hallpike specifically targets the **peripheral vestibular system** in the inner ear.

Question 56: Dix Hallpike maneuver is used to assess

A. Diagnose benign paroxysmal positional vertigo (BPPV) (Correct Answer)
B. Assess patency of Eustachian tube
C. Differentiate cochlear and retrocochlear deafness
D. Assess neonatal hearing loss

Explanation: ***Diagnose benign paroxysmal positional vertigo (BPPV)*** - The **Dix-Hallpike maneuver** is the gold standard diagnostic test for **BPPV**, specifically posterior canal BPPV, the most common type of BPPV. - The test involves moving the patient from sitting to supine position with the head turned 45° and extended 20° below horizontal. - A **positive test** elicits characteristic **rotatory nystagmus** with a **latency of 1-5 seconds**, **duration <60 seconds**, and **fatigability** on repeated testing. - The nystagmus characteristics (latency, fatigability, direction) help distinguish **peripheral BPPV** from rare central positional vertigo. *Assess patency of Eustachian tube* - **Eustachian tube patency** is assessed using **Valsalva maneuver**, **Toynbee test**, or **tympanometry**, which measure pressure equalization in the middle ear. - The Dix-Hallpike maneuver involves head positioning to provoke vertigo, not middle ear pressure testing. *Differentiate cochlear and retrocochlear deafness* - **Cochlear vs retrocochlear deafness** differentiation requires audiological tests: **pure tone audiometry**, **speech discrimination**, **auditory brainstem response (ABR)**, and **otoacoustic emissions (OAEs)**. - The Dix-Hallpike maneuver tests the vestibular system (balance), not the cochlear system (hearing). *Assess neonatal hearing loss* - **Neonatal hearing screening** uses **automated otoacoustic emissions (OAEs)** and **automated auditory brainstem response (AABR)**. - The Dix-Hallpike maneuver is a positional vertigo test requiring patient cooperation and has no role in hearing assessment at any age.

Question 57: Which of the following is not true regarding Vestibular neuroma

A. Nystagmus
B. High frequency sensorineural deafness
C. Absence of caloric response
D. Normal Corneal reflex (Correct Answer)

Explanation: ***Absence of caloric response*** - A **vestibular schwannoma** (acoustic neuroma) typically arises from the **vestibular nerve**, causing early impairment of **vestibular function**. - This often manifests as a **reduced or absent caloric response** in the affected ear, indicating damage to the peripheral vestibular system. *Normal Corneal reflex* - The **corneal reflex** tests the integrity of the **trigeminal nerve (CN V)** for the afferent limb and the **facial nerve (CN VII)** for the efferent limb. - While a large vestibular schwannoma can compress the trigeminal nerve and cause a diminished corneal reflex, early-stage tumors, or smaller tumors less commonly lead to this finding. *Nystagmus* - **Nystagmus** is an involuntary rhythmic eye movement and can be a sign of **vestibular dysfunction**, which is characteristic of a vestibular schwannoma. - It often presents as a **vestibular nystagmus**, which can be spontaneous or provoked, particularly in the early stages as the tumor affects balance pathways. *High frequency sensorineural deafness* - **Sensorineural hearing loss** is a classic and often the earliest symptom of a vestibular schwannoma, as the tumor compresses the **cochlear nerve**. - The hearing loss typically affects **higher frequencies** first and is progressive and unilateral.

Question 58: 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 59: Which of the following is the MOST common feature of superior canal dehiscence?

A. Positive Hennebert's sign
B. Oscillopsia
C. Positive Tullio's phenomenon (Correct Answer)
D. Positive Dix-Hallpike maneuver

Explanation: ***Positive Tullio's phenomenon*** - **Tullio's phenomenon** refers to **sound-induced disequilibrium** or nystagmus, which is a hallmark feature of superior canal dehiscence due to the open third window allowing sound to inappropriately stimulate the vestibular system. - This condition creates a **pressure-sensitive inner ear**, leading to vertigo, oscillopsia, and nystagmus triggered by loud sounds. *Positive Hennebert's sign* - **Hennebert's sign** indicates **nystagmus induced by pressure changes** in the external ear canal, often associated with Meniere's disease, but less specific for superior canal dehiscence. - While pressure sensitivity can occur, **sound-related symptoms (Tullio's phenomenon)** are more characteristic and common in superior canal dehiscence. *Oscillopsia* - **Oscillopsia**, the illusion of environmental motion, is a common symptom in superior canal dehiscence but is **not the most specific or defining feature** when compared to Tullio's phenomenon. - It results from **vestibulo-ocular reflex dysfunction** and can be caused by various vestibular disorders, not exclusively related to sound. *Positive Dix-Hallpike maneuver* - The **Dix-Hallpike maneuver** is used to diagnose **benign paroxysmal positional vertigo (BPPV)**, which is characterized by vertigo triggered by specific head positions due to otoconia dislodgement. - This maneuver is not typically positive or relevant for diagnosing **superior canal dehiscence**, where symptoms are more often sound or pressure-induced.

Question 60: At what angle is the caloric test done?

A. 30° (Correct Answer)
B. 15°
C. 60°
D. 45°

Explanation: ***30°*** - Positioning the head at **30 degrees** ensures the **horizontal semicircular canal** is in the vertical plane, making it most sensitive to thermal stimulation. - This orientation maximizes the **convection currents** within the endolymph, leading to a robust nystagmic response. *15°* - This angle does not optimally orient the **horizontal semicircular canal** for caloric testing, resulting in a less pronounced nystagmic response. - It would not efficiently induce the desired **endolymphatic movement** for evaluating vestibular function. *60°* - Positioning the head at **60 degrees** would place the horizontal semicircular canal at an angle that reduces its sensitivity to temperature changes. - This orientation would make the caloric test less effective in eliciting a clear and measurable **nystagmus**. *45°* - An angle of **45 degrees** would also not optimally align the **horizontal semicircular canal**, leading to a suboptimal caloric response. - It would not provide the best conditions for assessing the **vestibular system's reactivity** to thermal stimuli.

Practice by Chapter

Anatomy and Physiology of Balance

Practice Questions

Vestibular Testing Methods

Practice Questions

Videonystagmography

Practice Questions

Rotational Chair Testing

Practice Questions

Vestibular Evoked Myogenic Potentials

Practice Questions

Video Head Impulse Test

Practice Questions

Benign Paroxysmal Positional Vertigo

Practice Questions

Vestibular Neuritis

Practice Questions

Ménière's Disease

Practice Questions

Vestibular Migraine

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Central Vertigo

Practice Questions

Vestibular Rehabilitation

Practice Questions

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