Rotational Chair Testing — MCQs
Cervical Vestibular Evoked Myogenic Potential (cVEMP) detects lesion of -
Vestibular evoked myogenic potential (VEMP) is a tool for evaluating which of the following?
Following are the laboratory tests for the diagnosis of vestibular dysfunction except -
Caloric test assesses the function of ?
Positive Romberg test with eyes closed detects a defect in -
All are true about vestibular neuritis EXCEPT:
In a patient with right vestibular neuronitis, what will be the finding on the head impulse test?
Which of the following includes tests used to assess vestibular function?
A person presenting to the outpatient department with complaints of rotational vertigo and nausea in the morning, which worsens with changes in head position. What is your diagnosis?
In which condition is the Hamilton Ruler test sign positive?
Rotational Chair Testing Indian Medical PG Practice Questions and MCQs
Question 1: 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 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: 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 4: Caloric test assesses the function of ?
- A. Posterior semicircular canal
- B. Cochlea
- C. Anterior semicircular canal
- D. Horizontal semicircular canal (Correct Answer)
Explanation: ***Horizontal semicircular canal*** - The **caloric test** primarily assesses the function of the **horizontal (lateral) semicircular canal** by inducing temperature changes that stimulate or inhibit endolymph flow. - This test evaluates the **vestibulo-ocular reflex (VOR)**, which is crucial for maintaining gaze stability during head movements. *Posterior semicircular canal* - The **posterior semicircular canal** is mainly assessed by tests like the **Dix-Hallpike maneuver**, particularly for diagnosing **benign paroxysmal positional vertigo (BPPV)**. - It is responsible for detecting **head rotations in the sagittal plane**. *Cochlea* - The **cochlea** is the part of the inner ear responsible for **hearing**, converting sound vibrations into electrical signals. - Its function is assessed by **audiometry**, not the caloric test. *Anterior semicircular canal* - The **anterior (superior) semicircular canal** detects **head rotations in the sagittal plane**, similar to the posterior canal but in a different orientation. - While it contributes to overall vestibular function, the caloric test's thermal convection currents are most effective at stimulating the horizontally oriented canal.
Question 5: Positive Romberg test with eyes closed detects a defect in -
- A. Cerebellum
- B. Peripheral nerve
- C. Proprioceptive pathway (Correct Answer)
- D. Spinothalamic tract
Explanation: Proprioceptive pathway - A positive Romberg test indicates a loss of proprioception, meaning the patient cannot maintain balance when visual cues are removed, relying solely on somatosensory input [2]. - This suggests damage to the dorsal columns of the spinal cord or peripheral nerves that transmit proprioceptive information to the brain [1], [3]. Cerebellum - While cerebellar dysfunction also causes ataxia and balance problems, it would typically present as difficulty maintaining balance even with eyes open, referred to as cerebellar ataxia [2]. - A Romberg test primarily assesses the integrity of the proprioceptive system, distinguishing it from cerebellar issues where balance problems are evident regardless of visual input [2]. Peripheral nerve - Peripheral neuropathy can indeed lead to a positive Romberg test if the sensory nerves responsible for proprioception are affected [1]. - However, "Proprioceptive pathway" is a more direct and encompassing answer, as peripheral nerves are a component of this pathway, which also includes spinal cord tracts [3]. Spinothalamic tract - The spinothalamic tract primarily transmits sensations of pain and temperature, not proprioception [3]. - Damage to this tract would result in deficits in these specific sensory modalities, rather than a positive Romberg test [1].
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: 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 8: Which of the following includes tests used to assess vestibular function?
- A. Caloric test and Hallpike maneuver
- B. Hallpike maneuver and Fistula test
- C. Caloric test and Fistula test
- D. Caloric test, Hallpike maneuver, and Fistula test (Correct Answer)
Explanation: ***Caloric test, Hallpike maneuver, and Fistula test*** - This option includes **all three major bedside tests** for comprehensive vestibular assessment. - The **caloric test** evaluates the function of the **horizontal semicircular canal** and its central connections by introducing warm or cold water/air into the ear canal. - The **Hallpike maneuver** (Dix-Hallpike) is used to diagnose **benign paroxysmal positional vertigo (BPPV)** by assessing for nystagmus triggered by specific head positions. - The **Fistula test** assesses for a **perilymph fistula** by observing nystagmus or vertigo in response to pressure changes in the external ear canal. *Caloric test and Hallpike maneuver* - While both tests are valid for vestibular assessment, this option is **incomplete** as it omits the Fistula test, which is important for detecting perilymphatic fistulas. *Hallpike maneuver and Fistula test* - This combination is **incomplete** as it omits the caloric test, which is the gold standard for evaluating horizontal semicircular canal function and central vestibular pathways. *Caloric test and Fistula test* - This option is **incomplete** as it fails to include the Hallpike maneuver, a critical test for diagnosing **BPPV**, one of the most common causes of vertigo.
Question 9: A person presenting to the outpatient department with complaints of rotational vertigo and nausea in the morning, which worsens with changes in head position. What is your diagnosis?
- A. Labyrinthitis
- B. BPPV (Correct Answer)
- C. Vestibular neuronitis
- D. Meniere's disease
Explanation: ***BPPV (Benign Paroxysmal Positional Vertigo)*** - **Rotational vertigo** that is triggered by specific **head position changes** and often noticed upon waking or turning in bed is highly characteristic of BPPV. - The symptoms are typically brief, intense, and associated with **nausea**, resolving within seconds to minutes. *Labyrinthitis* - Labyrinthitis presents with **continuous vertigo** and often includes **hearing loss** and **tinnitus**, which are not mentioned in the patient's symptoms. - The vertigo in labyrinthitis is usually constant, not positional, and is caused by inflammation of the inner ear. *Vestibular neuronitis* - Vestibular neuronitis is characterized by **sudden, severe, and persistent vertigo** without hearing loss, often following a viral infection. - Unlike BPPV, the vertigo does not primarily worsen with specific head position changes but is more constant. *Meniere's disease* - Meniere's disease involves a classic triad of **recurrent episodes of vertigo**, **tinnitus**, and **fluctuating sensorineural hearing loss**, often accompanied by aural fullness. - The vertigo attacks are typically severe and last for hours, which is longer than the brief episodes seen in BPPV.
Question 10: In which condition is the Hamilton Ruler test sign positive?
- A. Anterior dislocation of shoulder (Correct Answer)
- B. Posterior dislocation of shoulder
- C. Luxatio erecta
- D. Acromioclavicular joint dislocation
Explanation: ***Anterior dislocation of shoulder*** - The **Hamilton Ruler test** is positive when a straight edge, like a ruler, can be laid across the **lateral aspect of the deltoid prominence** from the acromion to the lateral epicondyle. - This is indicative of the **loss of the normal rounded contour of the shoulder**, which occurs due to the humeral head dislocating anteriorly. *Acromioclavicular joint dislocation* - This condition presents with a **"step-off" deformity** at the AC joint and pain directly over the joint, but the overall contour of the shoulder glenohumeral joint is preserved. - The deltoid prominence remains intact, making the Hamilton Ruler test negative. *Posterior dislocation of shoulder* - In posterior dislocation, the **humeral head moves posteriorly**, and the anterior contour of the shoulder might appear flattened, but the characteristic prominent anterior bulge seen in anterior dislocation is absent. - The Hamilton Ruler test specifically assesses for the loss of the lateral deltoid prominence, which is more typical of anterior displacement. *Luxatio erecta* - **Luxatio erecta** is an inferior dislocation of the shoulder where the arm is fixed in an **abducted and externally rotated position**, making it appear "erect". - While a severe type of shoulder dislocation, the specific anatomical changes that lead to a positive Hamilton Ruler test (loss of lateral deltoid prominence with the humeral head moving anteriorly and medially) are not typically present in this configuration.
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