Vestibular Disorders Practice Questions

Q: Regarding acute vestibular neuronitis, all are true except?

High frequency sensorineural hearing loss. **Explanation:** **Acute Vestibular Neuronitis** is an acute peripheral vestibulopathy characterized by the sudden onset of severe vertigo, likely due to viral inflammation of the vestibular nerve (most commonly the superior division). 1. **Why Option B is the Correct Answer (The "Except"):** By definition, Vestibular Neuronitis involves **only the vestibular system**. There is **no cochlear involvement**. Therefore, hearing remains normal. If a patient presents with vertigo combined with sensorineural hearing loss (SNHL) and tinnitus, the diagnosis shifts to **Labyrinthitis**. Finding SNHL in a suspected case of neuronitis is a clinical "red flag" that points to other pathologies. 2. **Analysis of Other Options:** * **Option A:** Vertigo typically reaches its peak within hours and gradually subsides over 1–2 weeks as central compensation occurs. * **Option C:** Spontaneous horizontal-torsional nystagmus is a hallmark. It follows Alexander’s Law (beats towards the healthy ear) and is suppressed by visual fixation. * **Option D:** A significant number of cases are preceded by a viral **Upper Respiratory Tract Infection (URTI)**, supporting the theory of viral etiology (often HSV-1 reactivation). **High-Yield Clinical Pearls for NEET-PG:** * **HINTS Exam:** Used to differentiate peripheral vertigo (Neuronitis) from central vertigo (Stroke). Neuronitis shows a **positive Head Impulse Test**, direction-fixed nystagmus, and no Test of Skew deviation. * **Caloric Testing:** Shows **canal paresis** (reduced response) on the affected side. * **Management:** Acute phase is treated with **vestibular suppressants** (e.g., Labyrinthine sedatives like Prochlorperazine) for 48–72 hours only. Long-term recovery relies on **vestibular rehabilitation exercises**.

Q: What is a characteristic feature of central nystagmus?

More than 1 minute duration. ### Explanation Nystagmus is a rhythmic, involuntary oscillation of the eyes. Distinguishing between **Peripheral** (inner ear/vestibular nerve) and **Central** (brainstem/cerebellum) causes is a high-yield competency for NEET-PG. **1. Why "More than 1 minute duration" is correct:** In central vestibular lesions (e.g., stroke, tumors, or MS), the nystagmus is typically persistent. When performing the Dix-Hallpike maneuver, central nystagmus lacks the characteristic "fatigue" seen in BPPV. It begins immediately (no latency) and continues as long as the head is held in the provoking position, often lasting **well beyond 1 minute**. **2. Analysis of Incorrect Options:** * **A. Suppressed by optic fixation:** This is a hallmark of **Peripheral nystagmus**. In central lesions, the cerebellum is often involved; since the cerebellum is responsible for the fixation reflex, central nystagmus is **not suppressed** (and may even be enhanced) by focusing on an object. * **C. Fixed direction:** Central nystagmus is often **direction-changing** (e.g., changes direction based on the gaze). Peripheral nystagmus is typically unidirectional (fixed direction). * **D. Fatiguable:** Peripheral nystagmus (specifically in BPPV) is fatiguable, meaning the intensity diminishes with repeated testing. Central nystagmus is **non-fatiguable**. ### Clinical Pearls for NEET-PG: | Feature | Peripheral Nystagmus | Central Nystagmus | | :--- | :--- | :--- | | **Latency** | 3–20 seconds | No latency (Immediate) | | **Duration** | 1 minute (Persistent)** | | **Fatigability** | Yes | No | | **Fixation** | Suppresses nystagmus | No effect/Enhances | | **Direction** | Horizontal/Torsional | **Purely Vertical** (Upbeat/Downbeat) or Purely Torsional | **High-Yield Note:** Purely vertical nystagmus (upbeat or downbeat) is **always** central until proven otherwise.

Q: Spontaneous vertical nystagmus is seen in a lesion of which structure?

Midbrain. **Explanation:** The presence of **spontaneous vertical nystagmus** (upbeat or downbeat) is a hallmark sign of a **Central Vestibular Lesion**. 1. **Why Midbrain is Correct:** Vertical eye movements are controlled by the rostral midbrain (specifically the interstitial nucleus of Cajal and the rostral interstitial nucleus of the medial longitudinal fasciculus). Lesions in the **midbrain**, pons, or cerebellum disrupt these central pathways. Unlike peripheral disorders, central lesions do not require a specific head position to trigger nystagmus; it is often spontaneous and cannot be suppressed by visual fixation. 2. **Why Other Options are Incorrect:** * **Labyrinth & Vestibule:** These are peripheral vestibular structures. Lesions here (e.g., Meniere’s, Vestibular Neuronitis) typically produce **horizontal or horizontal-torsional nystagmus**. Purely vertical nystagmus is almost never peripheral in origin. * **Cochlea:** This structure is responsible for hearing, not balance. A lesion here would cause sensorineural hearing loss or tinnitus, not nystagmus. **High-Yield Clinical Pearls for NEET-PG:** * **Alexander’s Law:** Peripheral nystagmus increases in intensity when looking in the direction of the fast phase. * **Direction of Nystagmus:** * **Downbeat Nystagmus:** Classically associated with lesions at the **craniocervical junction** (e.g., Arnold-Chiari malformation). * **Upbeat Nystagmus:** Associated with lesions in the **medulla or midbrain**. * **Visual Fixation:** Suppresses peripheral nystagmus but has no effect on (or may even worsen) central nystagmus.

Q: Which of the following is NOT a cause of vertigo of vestibular origin?

Vertebrobasilar insufficiency. **Explanation:** The classification of vertigo is broadly divided into **Peripheral (Vestibular)** and **Central** causes. Peripheral vertigo arises from pathologies in the inner ear or the vestibular nerve, whereas central vertigo originates from the brainstem or cerebellum. **Why Vertebrobasilar Insufficiency (VBI) is the correct answer:** VBI is a **Central cause** of vertigo. It occurs due to transient ischemia of the brainstem, cerebellum, or visual cortex. While it presents with vertigo, it is typically associated with "D's": Diplopia, Dysarthria, Dysphagia, and Drop attacks. Since the pathology lies in the vascular supply to the central nervous system rather than the vestibular apparatus itself, it is not considered "vestibular origin" in the peripheral sense. **Analysis of Incorrect Options (Peripheral Causes):** * **Ménière's disease:** A peripheral disorder characterized by endolymphatic hydrops. It presents with the classic triad of episodic vertigo, sensorineural hearing loss, and tinnitus. * **BPPV:** The most common cause of peripheral vertigo, caused by canalithiasis (usually in the posterior semicircular canal). It is triggered by specific head movements. * **Vestibular neuronitis:** An acute peripheral vestibulopathy, often post-viral, involving inflammation of the vestibular nerve. It causes severe vertigo without hearing loss. **High-Yield Clinical Pearls for NEET-PG:** * **HINTS Exam:** Used to differentiate central from peripheral vertigo (Head Impulse, Nystagmus, Test of Skew). * **Nystagmus:** In peripheral vertigo, nystagmus is usually horizontal/rotatory and suppressed by visual fixation. In central vertigo (like VBI), it can be purely vertical and is **not** suppressed by fixation. * **Hearing Loss:** Common in peripheral causes (except BPPV/Neuronitis) but rare in central causes.

Q: Which of the following is NOT a test for vestibular function?

Acoustic reflex. The correct answer is **C. Acoustic reflex**. ### **Explanation** The **Acoustic Reflex** (also known as the Stapedial Reflex) is a test of **auditory function**, not vestibular function. It involves the involuntary contraction of the stapedius muscle in response to high-intensity sound stimuli. This reflex arc involves the **Cochlear nerve (CN VIII - Sensory)** and the **Facial nerve (CN VII - Motor)**. It is used clinically to assess middle ear pathologies (like Otosclerosis), cochlear function, and the integrity of the facial nerve. ### **Why the other options are Vestibular Tests:** * **Galvanic Stimulation (A):** This test uses electrical current applied to the mastoid to stimulate the **vestibular nerve** directly. It helps differentiate between lesions of the end-organ (labyrinth) and the vestibular nerve. * **Fistula Test (B):** This is used to identify a **perilymph fistula** (abnormal communication between the inner and middle ear). Applying pressure to the external canal induces vertigo and nystagmus if a fistula is present (Hennebert’s sign). * **Cold Caloric Test (D):** Part of the VNG/ENG battery, this uses thermal irrigation (water or air) to induce convection currents in the **Semicircular canals** (primarily horizontal). It assesses the Vestibulo-Ocular Reflex (VOR). ### **High-Yield Clinical Pearls for NEET-PG:** * **COWS Mnemonic:** For Caloric testing, **C**old **O**pposite, **W**arm **S**ame (refers to the direction of the fast phase of nystagmus). * **Hennebert’s Sign:** A positive fistula test without a clinical fistula, seen in **Meniere’s disease** or **Congenital Syphilis**. * **Tullio Phenomenon:** Vertigo induced by loud sounds; seen in Superior Semicircular Canal Dehiscence (SSCD). * **Gold Standard:** The **Electronystagmography (ENG)** or **Videonystagmography (VNG)** are the standard batteries for comprehensive vestibular evaluation.

Q: In the caloric test, left jerk nystagmus occurs when?

Cold water is poured in the right ear. ### Explanation The caloric test evaluates the function of the lateral semicircular canal by inducing convection currents in the endolymph through temperature changes. The direction of the resulting nystagmus is easily remembered by the mnemonic **COWS**: **C**old **O**pposite, **W**arm **S**ame. **1. Why Option A is Correct:** When **cold water** is poured into the **right ear**, it causes the endolymph to become denser and sink. This creates a current away from the ampulla (ampullofugal), leading to inhibition of the right vestibular system. This results in a slow component toward the right and a fast corrective component (jerk nystagmus) toward the **left** (the opposite side). **2. Analysis of Incorrect Options:** * **Option B:** Hot water in the right ear would cause endolymph to rise (ampullopetal), stimulating the right side and causing **right** jerk nystagmus (Warm Same). * **Option C:** Cold water in the left ear would cause nystagmus to the **right** (Cold Opposite). * **Option D:** Hot water in the left ear would cause nystagmus to the **left** (Warm Same). **3. Clinical Pearls for NEET-PG:** * **Patient Positioning:** The patient is placed supine with the head tilted **30° up** to bring the horizontal semicircular canal into a vertical plane. * **Standard Temperatures:** Cold water is **30°C** and warm water is **44°C** (7°C below and above body temperature). * **Canal Paresis:** A common finding in Meniere’s disease or Vestibular Neuronitis, where the response from one ear is significantly reduced compared to the other. * **Directional Preponderance:** When nystagmus in one direction (e.g., to the right) is stronger than the other, regardless of which ear is stimulated.

Q: In a patient, warm water (44 deg C) is applied to the right external auditory canal for 40 seconds. What type of nystagmus is expected?

Right side nystagmus. This question tests your knowledge of the **Caloric Test**, a clinical bedside procedure used to evaluate the function of the vestibular system (specifically the lateral semicircular canal). ### **Explanation of the Correct Answer** The direction of nystagmus during caloric testing is easily remembered by the mnemonic **COWS**: **C**old **O**pposite, **W**arm **S**ame. When **warm water (44°C)** is irrigated into the right ear, it causes the endolymph in the lateral semicircular canal to become less dense and rise (convection current). This movement is **ampullopetal** (toward the ampulla), which increases the firing rate of the vestibular nerve. This stimulates the vestibulo-ocular reflex, causing a slow phase of eye movement to the left and a **fast corrective phase (nystagmus) to the right**. Since nystagmus is named after the fast component, warm water in the right ear results in **Right-sided nystagmus**. ### **Analysis of Incorrect Options** * **B. Left side nystagmus:** This would occur if **cold water (30°C)** was applied to the right ear (Cold Opposite) or warm water was applied to the left ear. * **C. Circular nystagmus:** Caloric stimulation typically produces horizontal-torsional nystagmus. Circular (rotary) nystagmus is not a standard response to horizontal canal stimulation. * **D. No nystagmus:** This indicates a **dead labyrinth** (canal paresis), seen in conditions like vestibular neuritis or acoustic neuroma. ### **Clinical Pearls for NEET-PG** * **Standard Temperatures:** Cold water is 30°C; Warm water is 44°C (7°C below and above body temperature). * **Fitzgerald-Hallpike Technique:** This is the formal name for the bithermal caloric test. * **Positioning:** The patient's head must be elevated at **30°** to bring the lateral semicircular canal into a vertical plane. * **COWS Mnemonic:** Cold Opposite, Warm Same (refers to the direction of the fast component).

Question 1

Regarding acute vestibular neuronitis, all are true except?

Accepted Answer

High frequency sensorineural hearing loss

Answer

Tinnitus and vertigo developing over 1-2 weeks

Answer

Spontaneous nystagmus is present

Answer

Usually follows an upper respiratory tract infection

Question 2

A 60-year-old male presents with episodes of severe vertigo lasting for 4 hours, associated with vomiting. On examination, he has right horizontal nystagmus and mild right-sided sensorineural hearing loss during the episode. What is the most likely diagnosis?

Accepted Answer

Meniere's disease

Answer

Vertebrobasilar ischemic attacks

Answer

Labyrinthitis

Answer

Benign paroxysmal positional vertigo

Question 3

In a classical case of Meniere's disease, which one of the following statements is true?

Accepted Answer

Low frequency sensorineural deafness is often seen in pure tone audiogram

Answer

Carhart's Notch is a characteristic feature in puretone audiogram

Answer

Schwartz's sign is usually present in the tympanic membrane

Answer

Decompression of the fallopian canal is the treatment of choice

Question 4

What is a characteristic feature of central nystagmus?

Accepted Answer

More than 1 minute duration

Answer

Suppressed by optic fixation

Answer

Fixed direction

Answer

Fatiguable

Question 5

Spontaneous vertical nystagmus is seen in a lesion of which structure?

Accepted Answer

Midbrain

Answer

Labyrinth

Answer

Vestibule

Answer

Cochlea

Question 6

Which of the following is NOT a cause of vertigo of vestibular origin?

Accepted Answer

Vertebrobasilar insufficiency

Answer

Ménière's disease

Answer

Benign Paroxysmal Positional Vertigo (BPPV)

Answer

Vestibular neuronitis

Question 7

Which of the following is NOT a test for vestibular function?

Accepted Answer

Acoustic reflex

Answer

Galvanic stimulation

Answer

Fistula test

Answer

Cold caloric test

Question 8

All of the following conditions will produce nystagmus to the left except?

Accepted Answer

Irrigation of the left ear with cold water

Answer

Purulent labyrinthitis on the right side

Answer

Irrigation of the right ear with cold water

Answer

Irrigation of the left ear with warm water

Question 9

In the caloric test, left jerk nystagmus occurs when?

Accepted Answer

Cold water is poured in the right ear

Answer

Hot water is poured in the right ear

Answer

Cold water is poured in the left ear

Answer

Hot water is poured in the left ear

Question 10

In a patient, warm water (44
 deg C) is applied to the right external auditory canal for 40 seconds. What type of nystagmus is expected?

Accepted Answer

Right side nystagmus

Answer

Left side nystagmus

Answer

Circular nystagmus

Answer

No nystagmus

Vestibular Disorders — MCQs

Vestibular Disorders — MCQs

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