Vestibular Rehabilitation — MCQs

10 questions

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?

Down-beat nystagmus is seen in lesion of ?

Evidence based therapy of Bell's palsy include(s):

Epley's maneuver is indicated for the treatment of:

Hallpike maneuver is done for:

In a patient with right vestibular neuronitis, what will be the finding on the head impulse test?

Vestibular evoked myogenic potential (VEMP) is a tool for evaluating which of the following?

Chemical labyrinthectomy by transtympanic route is done in Meniere's disease using which drug?

Cervical Vestibular Evoked Myogenic Potential (cVEMP) detects lesion of -

Q10

Which intervention is best in patients operated for bilateral acoustic neuroma for hearing rehabilitation?

Vestibular Rehabilitation Indian Medical PG Practice Questions and MCQs

Question 1: 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 2: 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 3: Evidence based therapy of Bell's palsy include(s):

A. Steroid (Correct Answer)
B. Facial nerve massage
C. Acyclovir
D. Facial nerve stimulation

Explanation: ***Steroid*** - **Corticosteroids**, such as prednisone, are the mainstay of treatment for Bell's palsy, particularly when initiated early (within 72 hours of symptom onset) [1]. - They work by reducing **inflammation and swelling** of the facial nerve, which can alleviate compression and promote recovery. *Facial nerve massage* - While supportive therapies like physical therapy can be helpful for **muscle re-education** and preventing contractures, facial nerve massage itself is not an evidence-based therapy for improving nerve function in acute Bell's palsy. - Its efficacy in **nerve regeneration** or speeding recovery has not been scientifically proven. *Acyclovir* - **Antivirals** like acyclovir or valacyclovir are sometimes used in conjunction with steroids if a **herpes simplex virus (HSV) etiology** is suspected, but their standalone use for Bell's palsy is not evidence-based and their benefit in addition to steroids is debated [1]. - The primary evidence points to a viral etiology in some cases, but the direct benefit of antivirals over steroids alone is not consistently robust across studies. *Facial nerve stimulation* - **Electrical stimulation** of the facial nerve is not recommended and may even be harmful in the acute phase of Bell's palsy. - It has not been shown to improve outcomes and can potentially impede natural nerve regeneration or cause **synkinesis** [1].

Question 4: Epley's maneuver is indicated for the treatment of:

A. Positional vertigo (Correct Answer)
B. Otosclerosis
C. ASOM
D. CSOM

Explanation: ***Positional vertigo*** - **Epley's maneuver** is a highly effective, non-invasive treatment for **benign paroxysmal positional vertigo (BPPV)**, which is the most common type of positional vertigo. - It involves a series of specific head and body movements designed to reposition dislodged **otoconia (calcium carbonate crystals)** from the semicircular canals back into the utricle. *Otosclerosis* - **Otosclerosis** is a condition causing progressive conductive or mixed hearing loss due to abnormal bone growth in the middle ear, particularly around the stapes footplate. - Its treatment involves surgical intervention, such as **stapedectomy**, or amplification with hearing aids, not the Epley's maneuver. *ASOM* - **Acute suppurative otitis media (ASOM)** is an acute bacterial infection of the middle ear, typically presenting with ear pain, fever, and sometimes hearing loss. - It is primarily treated with **antibiotics** and pain management, and sometimes myringotomy for drainage. *CSOM* - **Chronic suppurative otitis media (CSOM)** is a persistent inflammation and infection of the middle ear and mastoid, often associated with a perforated tympanic membrane and ear discharge. - Management usually involves topical or systemic antibiotics, aural toilet, and potentially **tympanoplasty** or **mastoidectomy**.

Question 5: Hallpike maneuver is done for:

A. Vestibular function (Correct Answer)
B. Cochlear function
C. Audiometry
D. Corneal test

Explanation: ***Vestibular function*** - The **Dix-Hallpike maneuver** is a diagnostic test used to identify **benign paroxysmal positional vertigo (BPPV)**, which is a common cause of dizziness originating from the **vestibular system**. - It involves specific head and body movements to provoke dizziness and observe characteristic eye movements (**nystagmus**) indicative of otolith displacement within the semicircular canals. *Cochlear function* - **Cochlear function** relates to hearing and sound perception, which is assessed by tests like **audiometry** or otoacoustic emissions. - The Hallpike maneuver does not directly evaluate the function of the **cochlea**. *Audiometry* - **Audiometry** is a test used to assess a person's **hearing sensitivity** by measuring their ability to hear sounds of different frequencies and intensities. - It is distinct from the Hallpike maneuver, which focuses on **balance** and **vestibular dysfunction**. *Corneal test* - The **corneal reflex test** evaluates the integrity of the **trigeminal (CN V)** and **facial (CN VII)** nerves by observing an involuntary blink response to corneal stimulation. - This test is unrelated to vertigo or the **vestibular system**, which the Hallpike maneuver addresses.

Question 6: 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 7: 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 8: Chemical labyrinthectomy by transtympanic route is done in Meniere's disease using which drug?

A. Amikacin
B. Amoxycillin
C. Cyclosporine
D. Gentamicin (Correct Answer)

Explanation: ***Gentamicin*** - **Gentamicin** is an **aminoglycoside antibiotic** that is commonly used for chemical labyrinthectomy due to its **ototoxic** properties, particularly its selective toxicity to **vestibular hair cells** at lower doses. - When administered transtympanically, it achieves high concentrations in the **inner ear fluid**, effectively ablating the vestibular function and reducing severe vertigo in **Meniere's disease**. *Amikacin* - **Amikacin** is also an **aminoglycoside antibiotic** with ototoxic potential, but it is typically reserved for severe bacterial infections and is not the primary drug of choice for **chemical labyrinthectomy** in Meniere's disease. - While it can cause hearing loss, **gentamicin** has a more established and preferential effect on the **vestibular system** at therapeutic doses for Meniere's. *Amoxycillin* - **Amoxycillin** is a common **beta-lactam antibiotic** used for bacterial infections, and it does not possess **ototoxic** properties that would make it suitable for chemical labyrinthectomy. - It is primarily known for its antibacterial action and has no role in the management of vertigo in **Meniere's disease** via transtympanic administration. *Cyclosporine* - **Cyclosporine** is an **immunosuppressant drug** used to prevent organ rejection and treat autoimmune conditions; it does not have properties for chemical ablation of the labyrinth. - While some autoimmune components are sometimes considered in Meniere's disease, cyclosporine is not used for **transtympanic chemical labyrinthectomy**.

Question 9: 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 10: Which intervention is best in patients operated for bilateral acoustic neuroma for hearing rehabilitation?

A. Bilateral cochlear implant
B. Auditory brainstem implant (ABI) (Correct Answer)
C. Unilateral cochlear implant
D. High power hearing aid

Explanation: ***Auditory brainstem implant (ABI)*** - Patients with bilateral acoustic neuromas often suffer damage to both **auditory nerves** during surgery, rendering cochlear implants ineffective. - The **ABI** bypasses the damaged auditory nerves and directly stimulates the **cochlear nucleus** in the brainstem, allowing for sound perception. *Bilateral cochlear implant* - This intervention is suitable when the **auditory nerve** remains intact and functional, which is typically not the case after bilateral acoustic neuroma surgery. - Cochlear implants depend on the integrity of the auditory nerve to transmit electrical signals to the brain. *Unilateral cochlear implant* - Similar to bilateral cochlear implants, a unilateral implant relies on a functional **auditory nerve** on the implanted side. - In bilateral acoustic neuroma, both auditory nerves are usually compromised or sacrificed, making a unilateral implant unsuitable for binaural hearing rehabilitation. *High power hearing aid* - Hearing aids only amplify sound and are effective for **sensorineural hearing loss** where the cochlea and auditory nerve are still functional. - They would not be beneficial in cases where the auditory nerve is damaged or absent, as occurs after bilateral acoustic neuroma removal.

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