Video Head Impulse Test — MCQs
Cervical Vestibular Evoked Myogenic Potential (cVEMP) detects lesion of -
Best advantage of doing transcranial Doppler ultrasound?
In a patient with right vestibular neuronitis, what will be the finding on the head impulse test?
Caloric test assesses the function of ?
Which of the following includes tests used to assess vestibular function?
In Fitzgerald-Hallpike caloric test, cold-water irrigation at 30 degrees centigrade in the left ear in a normal person will induce -
A person presented to OPD with complaints of rotatory vertigo and nausea in the morning on change in position of the head. What is your diagnosis?
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 patient with jaundice is found to have a pancreatic head mass. What is the best diagnostic test?
All are true about vestibular neuritis EXCEPT:
Video Head Impulse Test 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: Best advantage of doing transcranial Doppler ultrasound?
- A. Detect brain blood vessels stenosis
- B. Detect AV malformation
- C. Detect emboli
- D. Detect vasospasm (Correct Answer)
Explanation: ***Detect vasospasm*** - **Transcranial Doppler (TCD) ultrasound** is highly effective for monitoring and detecting **cerebral vasospasm**, particularly after a **subarachnoid hemorrhage**. - It allows for non-invasive, continuous, and dynamic assessment of **blood flow velocities** in the **intracranial arteries**, which increase significantly during vasospasm. *Detect brain blood vessels stenosis* - While TCD can indicate increased flow velocities suggestive of **stenosis**, it is less accurate for precise anatomical localization and quantification compared to **CTA** or **MRA**. - Its ability to directly visualize the vessel lumen and the degree of stenosis is limited by its reliance on **flow dynamics**. *Detect AV malformation* - TCD can sometimes detect altered flow patterns associated with **arteriovenous malformations (AVMs)**, but it lacks the spatial resolution to definitively diagnose or characterize these complex vascular structures. - **Cerebral angiography** or **MRA** are the gold standards for diagnosing and mapping **AVMs**. *Detect emboli* - TCD can detect **microembolic signals (MES)**, which are transient high-intensity signals indicating the passage of emboli through the cerebral circulation. - However, while it can detect emboli, it is not its *best* or primary advantage compared to its utility in monitoring **vasospasm**, which directly impacts patient management and prognosis in certain acute conditions.
Question 3: 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 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: 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 6: In Fitzgerald-Hallpike caloric test, cold-water irrigation at 30 degrees centigrade in the left ear in a normal person will induce -
- A. Nystagmus to the left side
- B. Positional nystagmus
- C. Direction changing nystagmus
- D. Nystagmus to the right side (Correct Answer)
Explanation: ***Nystagmus to the right side*** - According to **COWS** (Cold Opposite, Warm Same) mnemonic, **cold-water irrigation** in the left ear inhibits the left horizontal semicircular canal. - This inhibition mimics a head turn to the right, causing nystagmus with the **fast phase to the opposite (right)** side. *Nystagmus to the left side* - This would occur with **warm-water irrigation** in the left ear, which excites the left horizontal semicircular canal. - Excitation would mimic a head turn to the left, causing nystagmus with the fast phase to the **same (left)** side. *Positional nystagmus* - This type of nystagmus is typically observed when the **head is moved into specific positions** and is indicative of benign paroxysmal positional vertigo (BPPV) or central lesions. - It is not the expected or primary response to a **caloric stimulus** in a normal individual. *Direction changing nystagmus* - This implies that the **direction of the nystagmus** changes depending on the gaze direction or with different stimuli, which can be a sign of a central vestibular lesion. - In a normal caloric test, the nystagmus direction following a specific stimulus (cold water in one ear) is **consistent**.
Question 7: A person presented to OPD with complaints of rotatory vertigo and nausea in the morning on change in position of the head. What is your diagnosis?
- A. BPPV (Correct Answer)
- B. Meniere's disease
- C. Vestibular neuronitis
- D. Labyrinthitis
Explanation: ***BPPV (Benign Paroxysmal Positional Vertigo)*** - The symptoms of **rotatory vertigo** and **nausea** that occur specifically with **changes in head position** (e.g., getting out of bed in the morning) are classic for BPPV. - BPPV is caused by the displacement of **otoconia** (calcium carbonate crystals) into one of the semicircular canals, typically the posterior canal. *Meniere's disease* - Characterized by a **triad of symptoms**: episodic vertigo, tinnitus (ringing in the ears), and fluctuating sensorineural hearing loss. - The vertigo in Meniere's disease is spontaneous and not typically triggered solely by specific head movements. *Vestibular neuronitis* - Presents as a **sudden onset, severe, persistent vertigo** often accompanied by nausea and vomiting, but without hearing loss. - Unlike BPPV, the vertigo is continuous for days and not solely precipitated by head position changes. *Labyrinthitis* - Similar to vestibular neuronitis but also involves **hearing loss** and/or tinnitus due to inflammation of the entire labyrinth. - The vertigo is continuous and severe, not intermittent or position-dependent like in BPPV.
Question 8: 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 9: A patient with jaundice is found to have a pancreatic head mass. What is the best diagnostic test?
- A. CT scan (Correct Answer)
- B. ERCP
- C. Ultrasound
- D. MRI
Explanation: ***CT scan*** - A **CT scan of the abdomen with contrast** is the initial investigation of choice for suspected pancreatic head mass due to its high diagnostic accuracy [1]. It provides detailed images of the pancreas, surrounding structures, and can help stage the disease [1]. - It effectively visualizes the **mass, evaluates for vascular invasion, and detects metastatic disease**, which are crucial for treatment planning [1]. *ERCP* - **Endoscopic retrograde cholangiopancreatography (ERCP)** is a therapeutic procedure primarily used for bile duct decompression, particularly in cases of obstructive jaundice [2]. - While it can visualize the bile ducts and pancreatic duct, it is **invasive** and not typically used as the primary diagnostic imaging modality for a pancreatic mass itself. *Ultrasound* - **Abdominal ultrasound** can detect a mass and dilated bile ducts, but it is operator-dependent and often has **limited sensitivity** for small pancreatic lesions, particularly in obese patients or those with bowel gas [1]. - It is often used as a first-line screening tool for jaundice but is usually followed by more definitive imaging like CT or MRI due to its **limited detail and penetration**. *MRI* - **Magnetic Resonance Imaging (MRI) with MRCP (Magnetic Resonance Cholangiopancreatography)** provides excellent soft tissue contrast, especially for assessing bile duct obstruction and assessing for vascular invasion [1]. - While highly sensitive, it is **more expensive and less readily available** than CT, making CT the preferred initial diagnostic test.
Question 10: 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.
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