Vestibular Neuritis — MCQs
Down-beat nystagmus is seen in lesion of ?
A case of CSOM presenting with vertigo can have any of the following except -
All are true about vestibular neuritis EXCEPT:
Vestibular evoked myogenic potential (VEMP) is a tool for evaluating which of the following?
Cervical Vestibular Evoked Myogenic Potential (cVEMP) detects lesion of -
Epley's maneuver is used in the treatment of:
Best surgery to relieve intractable vertigo in a Meniere's disease patient with profound hearing loss is?
COWS mnemonic is related to which of the following tests?
Which of the following is NOT typically seen in Meniere's disease?
Episodic vertigo, tinnitus, and normal hearing are characteristic features of which condition?
Vestibular Neuritis Indian Medical PG Practice Questions and MCQs
Question 1: Down-beat nystagmus is seen in lesion of ?
- A. Cerebellum (Correct Answer)
- B. Basal ganglia
- C. Hippocampus
- D. Brainstem
Explanation: ***Cerebellum*** * **Down-beat nystagmus (DBN)** is most commonly associated with lesions in the **craniocervical junction** and **posterior fossa**, particularly affecting the **flocculonodular lobe** of the cerebellum. * The cerebellum plays a crucial role in maintaining **gaze stability** and coordinating eye movements; damage to specific cerebellar pathways can disrupt the vestibulo-ocular reflex, leading to DBN [1]. *Brainstem* * While the **brainstem** contains critical circuits for eye movements, lesions here typically result in other forms of nystagmus, such as **up-beat nystagmus** or **gaze-evoked nystagmus**, depending on the specific structures involved [1]. * Damage to brainstem nuclei or pathways controlling vertical gaze is usually indicated by different patterns of oculomotor dysfunction. *Basal ganglia* * Lesions in the **basal ganglia** are primarily associated with **movement disorders** like Parkinson's disease or Huntington's disease. * They do not typically cause primary nystagmus; any ocular abnormalities would generally be secondary to global motor control issues rather than direct involvement in oculomotor pathways. *Hippocampus* * The **hippocampus** is a key structure involved in **memory formation** and spatial navigation. * Lesions in the hippocampus cause **amnesia** and navigational deficits, but they are not directly involved in eye movement control or the generation of nystagmus.
Question 2: A case of CSOM presenting with vertigo can have any of the following except -
- A. Dural sinus thrombosis (Correct Answer)
- B. Cerebellar abscess
- C. Fistula with semicircular canal
- D. Any of the above
Explanation: ***Dural sinus thrombosis (Correct - Does NOT typically cause vertigo)*** - Dural sinus thrombosis is an intracranial complication of CSOM that presents with **headache**, **papilledema**, **seizures**, and **focal neurological deficits** - **Vertigo is NOT a characteristic feature** of dural sinus thrombosis - While it's a serious complication of CSOM, it does not directly affect the vestibular system, making it the exception in this list *Cerebellar abscess (Incorrect - DOES cause vertigo)* - Cerebellar abscess is a serious intracranial complication of CSOM that **commonly causes vertigo** - Due to proximity to the **vestibular nuclei** and brainstem pathways, cerebellar pathology disrupts balance and coordination - Presents with prominent **vertigo**, **ataxia**, **nystagmus**, and other cerebellar signs *Fistula with semicircular canal (Incorrect - DOES cause vertigo)* - **Labyrinthine fistula** is a direct cause of vertigo in CSOM - Erosion from chronic infection creates an abnormal communication between the middle ear and inner ear (commonly affects the **lateral semicircular canal**) - Produces **pressure-induced vertigo** (positive fistula test) as pressure changes directly stimulate the vestibular system - Classic presentation: vertigo triggered by loud sounds (Tullio phenomenon) or pressure changes *Any of the above (Incorrect)* - This option is incorrect because NOT all listed complications cause vertigo - While cerebellar abscess and labyrinthine fistula are well-established causes of vertigo in CSOM, dural sinus thrombosis does not typically present with vertigo - Therefore, "any of the above" is not accurate
Question 3: 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 4: 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 5: 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 6: Epley's maneuver is used in the treatment of:
- A. BPPV (Benign paroxysmal positional vertigo) (Correct Answer)
- B. Infective labyrinthitis
- C. Cervical spondylosis
- D. Tinnitus
Explanation: ***BPPV (Benign paroxysmal positional vertigo)*** - The **Epley's maneuver** is a repositioning procedure specifically designed to treat **benign paroxysmal positional vertigo (BPPV)** by moving displaced otoconia out of the semicircular canals. - BPPV is characterized by brief episodes of **vertigo** triggered by specific head movements. *Infective labyrinthitis* - **Infective labyrinthitis** is an inflammation of the inner ear, typically caused by a viral or bacterial infection, leading to vertigo, hearing loss, and tinnitus. - Its treatment involves antibiotics or antivirals and symptomatic relief, not physical maneuvers. *Cervical spondylosis* - **Cervical spondylosis** is a degenerative condition affecting the neck vertebrae and discs, causing neck pain, stiffness, and sometimes neurological symptoms. - Treatment focuses on physical therapy, pain management, and sometimes surgery, not the Epley's maneuver. *Tinnitus* - **Tinnitus** is the perception of noise or ringing in the ears without an external source, often a symptom of an underlying condition. - Management involves addressing the underlying cause, sound therapy, and cognitive behavioral therapy, with no role for the Epley's maneuver.
Question 7: Best surgery to relieve intractable vertigo in a Meniere's disease patient with profound hearing loss is?
- A. Vestibular neurectomy
- B. Endolymphatic sac decompression
- C. Cochleosacculotomy
- D. Surgical Labyrinthectomy (Correct Answer)
Explanation: **Surgical Labyrinthectomy** * **Labyrinthectomy** is the most effective surgical option for intractable vertigo in Meniere's disease when the affected ear also has **profound hearing loss**, as it completely ablates the vestibular function of the inner ear. * Since the patient already has profound hearing loss, the loss of residual hearing from this procedure is not a significant concern, making it an ideal choice for **vertigo control**. *Vestibular neurectomy* * **Vestibular neurectomy** is a highly effective procedure for intractable vertigo, as it aims to selectively cut the vestibular nerve while preserving hearing. * However, it is a more complex surgical approach compared to labyrinthectomy and is typically reserved for patients with **serviceable hearing** that they wish to preserve. *Endolymphatic sac decompression* * **Endolymphatic sac decompression** is a surgical procedure designed to improve the reabsorption of endolymph, thereby reducing the pressure and symptoms of Meniere's disease, including vertigo and hearing loss. * While it may improve vertigo symptoms, it is less consistently effective than ablative procedures for intractable vertigo and its primary benefit is to **preserve hearing**, which is not a priority in a patient with profound hearing loss. *Cochleosacculotomy* * **Cochleosacculotomy** involves making a small opening in the labyrinth to drain endolymph, aiming to reduce endolymphatic hydrops and alleviate vertigo. * Though it can help with vertigo, it carries a high risk of causing complete hearing loss in the operated ear and offers less reliable vertigo control compared to a labyrinthectomy, especially when profound hearing loss is already present.
Question 8: COWS mnemonic is related to which of the following tests?
- A. Romberg test
- B. Caloric test (Correct Answer)
- C. Fistula test
- D. Hallpike positional test
Explanation: **Explanation:** The **COWS mnemonic** is a fundamental clinical tool used to interpret the results of the **Caloric Test** (part of the Electronystagmography battery). The test involves irrigating the external auditory canal with water or air that is either warmer or cooler than body temperature to induce convection currents in the endolymph of the lateral semicircular canal. The mnemonic stands for: * **C**old – **O**pposite * **W**arm – **S**ame This describes the direction of the **fast component of nystagmus**: cold water irrigation induces nystagmus with the fast phase beating toward the opposite ear, while warm water induces nystagmus beating toward the same (irrigated) ear. **Analysis of Incorrect Options:** * **Romberg test:** A test of postural stability used to differentiate between sensory and cerebellar ataxia; it does not involve thermal stimulation or the COWS mnemonic. * **Fistula test:** Used to identify a labyrinthine fistula (usually in the lateral canal). A positive result (Hennebert’s sign) is nystagmus/vertigo induced by pressure changes in the EAC. * **Hallpike positional test:** The gold standard for diagnosing Benign Paroxysmal Positional Vertigo (BPPV) by eliciting characteristic geotropic nystagmus. **Clinical Pearls for NEET-PG:** * **Fitzgerald-Hallpike Technique:** The standard caloric test using water at 30°C (Cold) and 44°C (Warm). * **Canal Paresis:** A reduced response on one side (calculated using Jongkees’ formula), indicating a peripheral vestibular lesion. * **Dead Labyrinth:** No response to both cold and warm irrigation. * **Directional Preponderance:** Nystagmus in one direction is stronger than the other.
Question 9: Which of the following is NOT typically seen in Meniere's disease?
- A. Tinnitus
- B. Hearing loss
- C. Loss of consciousness (Correct Answer)
- D. Vertigo
Explanation: ### Explanation **Meniere’s Disease** (Endolymphatic Hydrops) is a disorder of the inner ear characterized by an increase in the volume and pressure of the endolymph. The hallmark of this condition is a **triad of symptoms** affecting the vestibular and cochlear systems. **Why "Loss of Consciousness" is the Correct Answer:** Meniere’s disease is a peripheral vestibular disorder. While it causes severe vertigo and imbalance, it **does not** affect the Reticular Activating System (RAS) or cerebral perfusion. Therefore, it does not cause loss of consciousness (syncope). If a patient presents with vertigo and loss of consciousness, clinicians should investigate central causes or cardiovascular issues (e.g., Vertebrobasilar insufficiency). **Analysis of Incorrect Options:** * **Vertigo (Option D):** This is the most distressing symptom. It occurs in episodic, paroxysmal attacks lasting 20 minutes to several hours, often accompanied by nausea and vomiting. * **Hearing Loss (Option B):** Characteristically **sensorineural** and **fluctuating**. In early stages, it typically affects **low frequencies** (rising curve on audiometry). * **Tinnitus (Option A):** Usually described as a low-pitched, "roaring" or "seashell" sound that often worsens during an acute attack. **High-Yield Clinical Pearls for NEET-PG:** * **Pathology:** Distension of the endolymphatic system (Endolymphatic Hydrops), most commonly seen in the **scala media** and saccule. * **Lermoyez Syndrome:** A variant where hearing improves during a vertigo attack ("the phenomenon of reverse symptoms"). * **Tullio Phenomenon:** Vertigo induced by loud sounds (occasionally seen in Meniere's). * **Tumarkin’s Otolithic Crisis:** Sudden "drop attacks" without loss of consciousness due to utricular/saccular dysfunction. * **Management:** Low-salt diet, diuretics (Acetazolamide), and Vestibular suppressants (Betahistine). Chemical labyrinthectomy uses **Gentamicin** (vestibulotoxic).
Question 10: Episodic vertigo, tinnitus, and normal hearing are characteristic features of which condition?
- A. Acoustic neuroma
- B. Meniere's disease (Correct Answer)
- C. Vestibular neuritis
- D. All of the above
Explanation: ### Explanation **Meniere’s Disease (Endolymphatic Hydrops)** is characterized by a classic triad of episodic vertigo, tinnitus, and sensorineural hearing loss (SNHL). While the question mentions "normal hearing," it is a high-yield clinical fact that in the **early stages** of Meniere’s disease, hearing often returns to normal between episodes. The vertigo is spontaneous, lasting 20 minutes to several hours, and is typically associated with a feeling of aural fullness. #### Analysis of Options: * **Meniere’s Disease (Correct):** It is the most likely diagnosis for episodic vertigo and tinnitus. Although SNHL is a hallmark, it is characteristically fluctuating and may not be persistent in early presentations. * **Acoustic Neuroma:** This presents with **progressive**, unilateral SNHL and persistent tinnitus. Vertigo is rarely episodic; instead, patients experience gradual imbalance due to central compensation as the tumor grows slowly. * **Vestibular Neuritis:** This involves a sudden, severe attack of vertigo lasting days. Crucially, there are **no auditory symptoms** (no tinnitus, no hearing loss), as the pathology is limited to the vestibular nerve. #### NEET-PG High-Yield Pearls: * **Pathophysiology:** Distension of the endolymphatic system (Endolymphatic hydrops) due to increased pressure. * **Hearing Loss Pattern:** Early Meniere’s typically shows **low-frequency SNHL** (rising curve on audiometry). * **Lermoyez Syndrome:** A variant where hearing improves during a vertigo attack. * **Tullio Phenomenon:** Vertigo induced by loud sounds (also seen in Superior Semicircular Canal Dehiscence). * **Management:** Low-salt diet and diuretics are first-line; Betahistine is used for prophylaxis.
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