Videonystagmography — MCQs

10 questions

In Fitzgerald-Hallpike caloric test, cold-water irrigation at 30 degrees centigrade in the left ear in a normal person will induce -

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

Dix-Hallpike maneuver is used to assess-

A 47-year-old man presents to the emergency room with symptoms of dizziness and difficulty walking. He describes his dizziness as a spinning sensation of the room with associated nausea and vomiting. Which of the following findings suggests the vertigo is peripheral in origin?

Nystagmus is associated with all except:

All are true about vestibular neuritis EXCEPT:

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

Q8Easy

COWS mnemonic is related to which of the following tests?

Q9Easy

Which of the following is NOT typically seen in Meniere's disease?

Q10Medium

Episodic vertigo, tinnitus, and normal hearing are characteristic features of which condition?

Videonystagmography Indian Medical PG Practice Questions and MCQs

Question 1: 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 2: 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 3: 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 4: A 47-year-old man presents to the emergency room with symptoms of dizziness and difficulty walking. He describes his dizziness as a spinning sensation of the room with associated nausea and vomiting. Which of the following findings suggests the vertigo is peripheral in origin?

A. optic neuritis
B. tinnitus (Correct Answer)
C. bidirectional nystagmus
D. vertical nystagmus

Explanation: ***tinnitus*** - The presence of **tinnitus**, along with **hearing loss** and **vertigo**, is highly suggestive of a peripheral cause of vertigo, such as **Meniere's disease** [1]. - Peripheral vertigo disorders often involve the **inner ear** structures, which are responsible for both balance and hearing [1]. *optic neuritis* - **Optic neuritis** is an **inflammation of the optic nerve** and is a neurological symptom typically associated with **central nervous system disorders**, such as **multiple sclerosis**. - It does not directly cause vertigo, although neurological conditions can present with balance disturbances. *bidirectional nystagmus* - **Bidirectional nystagmus** (nystagmus that changes direction) is a strong indicator of **central vertigo**, often caused by lesions in the brainstem or cerebellum [2]. - Peripheral nystagmus is typically **unidirectional** and horizontal or rotatory. *vertical nystagmus* - **Vertical nystagmus** (up-beating or down-beating) is almost always a sign of **central vertigo**, indicating damage to the brainstem or cerebellum [2]. - Peripheral vestibular lesions typically cause **horizontal or torsional nystagmus**.

Question 5: Nystagmus is associated with all except:

A. Vestibular disease
B. Cochlear disease (Correct Answer)
C. Arnold-Chiari malformation
D. Cerebellar disease

Explanation: ***Cochlear disease*** - **Cochlear disease** primarily affects **hearing** through damage to the cochlea, the auditory part of the inner ear [3]. - It does not directly involve the vestibular system, which controls balance and eye movements, and therefore is not associated with nystagmus. *Vestibular disease* - **Vestibular disease** affects the **balance system** of the inner ear and can cause nystagmus, often accompanied by vertigo and dizziness [2], [4]. - Examples include **benign paroxysmal positional vertigo (BPPV)**, **Meniere's disease**, and **vestibular neuronitis**. *Arnold-Chiari malformation* - **Arnold-Chiari malformation** involves structural defects in the cerebellum and brainstem, which can disrupt the normal control of eye movements. - This often leads to **downbeat nystagmus** or other forms of central nystagmus due to compression of the **brainstem** and **cerebellum**. *Cerebellar disease* - The **cerebellum** plays a crucial role in coordinating smooth eye movements and maintaining gaze stability. - **Cerebellar disease** can cause various types of nystagmus, such as **gaze-evoked nystagmus** and **rebound nystagmus**, due to impaired motor control [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: 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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