Dizziness and Vertigo — MCQs

10 questions

A 25-year-old woman presents with episodes of dizziness, tinnitus, and hearing loss in the right ear. What is the most likely diagnosis?

Difference between central and peripheral vertigo:

Which of the following is the MOST accurate definition of vertigo?

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 case of CSOM presenting with vertigo can have any of the following except -

All are true about vestibular neuritis EXCEPT:

All of the following are seen in Meniere's Disease except:

Isolated painful third nerve palsy is a feature of aneurysms of:

A 60-year-old man presents to his primary care physician complaining that he often feels as if the room is spinning when he gets up from a recumbent position or turns his head. He has not lost consciousness and has had no chest pain. He has no cardiac history, and a recent treadmill test showed no abnormalities. On examination, the sensation can be produced by rapidly turning the head. It can be reproduced many times, but it eventually ceases. Nystagmus is elicited. Hearing is normal. Which of the following is the MOST likely mechanism for this patient's symptoms?

Q10

A 65-year-old woman complains of recurrent episodes of sudden-onset dizziness and nausea. She notices an abrupt onset of a spinning sensation when rolling over or sitting up in bed. The symptoms last for 30 seconds and then completely resolve. She has no hearing change or other neurologic symptoms, and her physical examination is completely normal. A Dix-Hallpike maneuver reproduces her symptoms. Which of the following findings on vestibular testing favors the diagnosis of benign paroxysmal positional vertigo (BPPV) over central positional vertigo?

Dizziness and Vertigo Indian Medical PG Practice Questions and MCQs

Question 1: A 25-year-old woman presents with episodes of dizziness, tinnitus, and hearing loss in the right ear. What is the most likely diagnosis?

A. Labyrinthitis
B. Ménière's disease (Correct Answer)
C. Acoustic neuroma
D. Benign paroxysmal positional vertigo

Explanation: ***Ménière's disease*** - This condition is characterized by a classic triad of **episodic vertigo (dizziness)**, fluctuating **sensorineural hearing loss**, and **tinnitus**, often accompanied by aural fullness, typically affecting one ear. - The symptoms arise from an accumulation of **endolymph** in the inner ear, leading to increased pressure and dysfunction. *Labyrinthitis* - **Labyrinthitis** is an inflammation of the inner ear, usually viral, causing sudden, severe **vertigo** potentially with hearing loss and tinnitus. - Unlike Meniere's disease, **hearing loss** and **tinnitus** in labyrinthitis are usually constant rather than episodic or fluctuating. *Acoustic neuroma* - An **acoustic neuroma** (vestibular schwannoma) is a benign tumor on the eighth cranial nerve, often causing **gradual, progressive unilateral hearing loss**, tinnitus, and **balance issues**, but typically not episodic severe dizziness. - While it can cause hearing loss and tinnitus, the **episodic nature of vertigo** is less common than in Ménière's disease. *Benign paroxysmal positional vertigo* - **BPPV** is characterized by sudden, **brief episodes of vertigo** triggered by specific head movements, caused by dislodged **otoconia** in the semicircular canals. - Critically, BPPV does **not** typically cause associated **hearing loss or tinnitus**, which are prominent symptoms in the presented case.

Question 2: Difference between central and peripheral vertigo:

A. Tinnitus and deafness are often present in peripheral vertigo (Correct Answer)
B. Multidirectional nystagmus that changes with gaze direction is common in central vertigo
C. Nystagmus associated with central vertigo is unidirectional
D. Central is more severe than peripheral vertigo

Explanation: ***Tinnitus and deafness are often present in peripheral vertigo*** - **Peripheral vertigo** arises from problems in the **inner ear** or **vestibulocochlear nerve**, which are also responsible for hearing, thus often presenting with associated **tinnitus** or **hearing loss** [1]. - Conditions like **Meniere's disease** and **labyrinthitis** are classic examples where auditory symptoms accompany the sensation of dizziness [1]. *Multidirectional nystagmus that changes with gaze direction is common in central vertigo* - This statement is **incorrect** as **multidirectional nystagmus** (e.g., vertical, purely torsional, or changing direction with gaze) that does not suppress with fixation is a characteristic feature of **central vertigo** [2]. - **Nystagmus** in central vertigo is often **purely vertical** or **torsional**, can change direction with gaze, and does **not typically fatigue** or habituate. *Nystagmus associated with central vertigo is unidirectional* - This statement is **incorrect** because **unidirectional nystagmus** (fast phase always beating in one constant direction regardless of gaze) is more characteristic of **peripheral vertigo**. - In **central vertigo**, nystagmus can be **multidirectional**, **purely vertical**, or **torsional**, and its direction may **change with the direction of gaze**. *Central is more severe than peripheral vertigo* - This statement is **incorrect** because the **severity of vertigo perception** is often **more intense** in **peripheral vertigo** due to the sudden and often disabling vestibular imbalance. - While **central vertigo** can be associated with more **severe underlying neurological conditions**, the *sensation* of spinning itself is typically perceived as less severe and more often accompanied by other neurological deficits, rather than solely intense spinning.

Question 3: Which of the following is the MOST accurate definition of vertigo?

A. Sense of pressure in the ear
B. Infection of the inner ear
C. Subjective sense of imbalance
D. Sensation of spinning or whirling (Correct Answer)

Explanation: ***Correct: Sensation of spinning or whirling*** - Vertigo is medically defined as an **illusion of movement**, typically a sensation that the patient or their surroundings are spinning, rotating, or whirling. - This is the **hallmark feature** that distinguishes vertigo from other forms of dizziness according to **Harrison's Principles** and standard ENT textbooks. - The **vestibular system** provides spatial orientation, and when disrupted (as in **BPPV, Meniere's disease, vestibular neuritis**), it creates this false perception of rotational movement. - The spinning sensation can be subjective (patient feels they are moving) or objective (environment appears to move). *Incorrect: Subjective sense of imbalance* - This describes **disequilibrium** or nonspecific dizziness, NOT vertigo specifically. - Imbalance without rotational sensation suggests different pathologies like **cerebellar dysfunction, proprioceptive loss**, or multisensory deficit. - While vertigo can cause secondary imbalance, the **defining feature** is the illusory movement, not just imbalance alone. *Incorrect: Sense of pressure in the ear* - Aural fullness or ear pressure is an **associated symptom** in conditions like **Meniere's disease** or **eustachian tube dysfunction**. - This is not the definition of vertigo but rather a **concurrent symptom** that may accompany vestibular disorders. *Incorrect: Infection of the inner ear* - Inner ear infections like **labyrinthitis** or **vestibular neuritis** are **etiologies** (causes) that can produce vertigo. - An infection is a pathological process, not the definition of the symptom itself—many non-infectious causes also produce vertigo.

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: 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 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: All of the following are seen in Meniere's Disease except:

A. Fullness of ear
B. Ear Pain (Correct Answer)
C. Vertigo
D. Tinnitus

Explanation: ***Ear Pain*** - **Otalgia** (ear pain) is not a typical symptom of **Meniere's disease**. - While patients may experience discomfort due to pressure, sharp or significant pain is generally absent. *Fullness of ear* - A sensation of **aural fullness** or pressure in the affected ear is a characteristic symptom of Meniere's disease, often preceding a vertiginous attack. - This symptom is thought to be due to the buildup of **endolymphatic fluid** within the inner ear. *Vertigo* - **Episodic rotational vertigo** is a hallmark symptom of Meniere's disease, significantly impacting daily activities and often accompanied by nausea and vomiting. - These attacks are typically sudden, severe, and can last from 20 minutes to several hours. *Tinnitus* - **Tinnitus**, often described as a ringing, buzzing, or roaring sound, is a common symptom in patients with Meniere's disease. - It usually fluctuates in intensity and can worsen before or during a vertigo attack.

Question 8: Isolated painful third nerve palsy is a feature of aneurysms of:

A. Aneurysm of the posterior communicating artery (Correct Answer)
B. Aneurysm of the anterior communicating artery
C. Aneurysm of the vertebrobasillary artery
D. Aneurysm of the ophthalmic artery

Explanation: ***Aneurysm of the posterior communicating artery*** - An aneurysm of the **posterior communicating artery (PCOM)** can compress the ipsilateral **oculomotor nerve (CN III)** as it exits the brainstem. - This compression typically affects the **superficial parasympathetic fibers** first, leading to a **dilated pupil** (mydriasis) along with ophthalmoplegia and ptosis, making the third nerve palsy "painful" and "isolated" without other focal neurological deficits. *Aneurysm of the anterior communicating artery* - Aneurysms of the **anterior communicating artery (ACoM)** are more commonly associated with **subarachnoid hemorrhage** and can cause **visual field defects** or **frontal lobe dysfunction**, but generally not isolated CN III palsy. - While rupture can lead to various neurological deficits, isolated painful third nerve palsy due to ACoM aneurysm is atypical. *Aneurysm of the vertebrobasillary artery* - Aneurysms in the **vertebrobasillar system** typically present with symptoms related to **brainstem compression** or ischemia, such as cranial nerve palsies beyond the third nerve, ataxia, or motor/sensory deficits. - Isolated third nerve palsy is an uncommon presentation for vertebrobasilar aneurysms compared to PCOM aneurysms. *Aneurysm of the ophthalmic artery* - **Ophthalmic artery aneurysms** are usually **intraorbital** and can cause **visual loss** due to direct compression of the **optic nerve (CN II)** or orbital structures. - They are less likely to cause isolated painful third nerve palsy, as the third nerve's course is generally not directly compromised by ophthalmic artery aneurysms.

Question 9: A 60-year-old man presents to his primary care physician complaining that he often feels as if the room is spinning when he gets up from a recumbent position or turns his head. He has not lost consciousness and has had no chest pain. He has no cardiac history, and a recent treadmill test showed no abnormalities. On examination, the sensation can be produced by rapidly turning the head. It can be reproduced many times, but it eventually ceases. Nystagmus is elicited. Hearing is normal. Which of the following is the MOST likely mechanism for this patient's symptoms?

A. Insufficient cerebral perfusion
B. Insufficient cardiac output
C. Aberrant stimulation of hair cells (Correct Answer)
D. Hair cell death in the semicircular canals

Explanation: ***Aberrant stimulation of hair cells*** - The symptoms of **positional vertigo** (room spinning with head movements) and fatigable nystagmus without hearing loss are characteristic of **benign paroxysmal positional vertigo (BPPV)**. - BPPV is caused by dislodged **otoconia** (calcium carbonate crystals) from the utricle that enter the semicircular canals, leading to inappropriate stimulation of the **hair cells** during head movements. *Insufficient cerebral perfusion* - While inadequate cerebral perfusion can cause dizziness or lightheadedness, it typically presents as **presyncope** or orthostatic hypotension, not the rotatory sensation of vertigo. - The patient's symptoms are specifically triggered by head movements and are not associated with changes in body position leading to systemic hypotension. *Insufficient cardiac output* - Insufficient cardiac output can lead to generalized weakness, lightheadedness, or syncope, but it rarely causes the specific sensation of **spinning vertigo** or movement-induced **nystagmus**. - The patient's recent **normal treadmill test** and lack of cardiac history make primary cardiac issues an unlikely cause for these specific symptoms. *Hair cell death in the semicircular canals* - **Hair cell death** would typically result in a permanent or persistent deficit, not a transient, positional vertigo that can be reproduced but eventually ceases (fatigues). - Conditions involving hair cell damage, such as **Meniere's disease** or **labyrinthitis**, often present with additional symptoms like hearing loss or tinnitus, which are absent in this patient.

Question 10: A 65-year-old woman complains of recurrent episodes of sudden-onset dizziness and nausea. She notices an abrupt onset of a spinning sensation when rolling over or sitting up in bed. The symptoms last for 30 seconds and then completely resolve. She has no hearing change or other neurologic symptoms, and her physical examination is completely normal. A Dix-Hallpike maneuver reproduces her symptoms. Which of the following findings on vestibular testing favors the diagnosis of benign paroxysmal positional vertigo (BPPV) over central positional vertigo?

A. habituation occurs (Correct Answer)
B. absence of a latency period
C. moderate vertigo
D. absence of fatigability

Explanation: The phenomenon of **habituation**, where symptoms lessen with repeated positional changes, is characteristic of **BPPV** due to canalith dissolution or movement away from the cupula. In central positional vertigo, habituation typically does not occur, and the nystagmus may be persistent. **BPPV** typically presents with a **latency period** of a few seconds (usually 2-20 seconds) between the provocative maneuver and the onset of nystagmus and vertigo. The absence of a latency period is a characteristic more consistent with **central positional vertigo**. The severity of vertigo (moderate vs. severe) is not a reliable differentiating factor between BPPV and central positional vertigo, as both can cause significant discomfort. While BPPV often causes **severe vertigo with nystagmus**, central causes can also present with varying intensities of dizziness. **Fatigability**, meaning the nystagmus and vertigo decrease in intensity with repeated maneuvers, is a hallmark of **BPPV**. The **absence of fatigability** suggests a central cause, where nystagmus often persists or even increases with repeated testing.

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