Vestibular Disorders Practice Questions

Q: Downbeat nystagmus is characteristic of which of the following?

Posterior fossa lesion. **Explanation:** **Downbeat nystagmus** is a type of central vestibular nystagmus where the fast phase is directed downwards. It is a hallmark sign of a **Posterior Fossa Lesion**, specifically those involving the **craniocervical junction** (e.g., Arnold-Chiari malformation) or the **cerebellum** (specifically the vestibulocerebellum/flocculus). 1. **Why it is correct:** The vertical eye movement pathways are regulated by the brainstem and cerebellum within the posterior fossa. Lesions at the level of the foramen magnum or the cerebellar flocculus disrupt the inhibitory control over the vestibular nuclei, resulting in an upward drift of the eyes followed by a corrective downward fast phase (downbeat nystagmus). 2. **Why other options are incorrect:** * **Vestibular and Labyrinthine lesions (A & D):** Peripheral vestibular disorders (inner ear) typically cause **horizontal-torsional** nystagmus. Purely vertical nystagmus (upbeat or downbeat) is almost always a sign of a central nervous system pathology. * **Cerebellar lesion (C):** While cerebellar lesions *can* cause downbeat nystagmus, "Posterior Fossa Lesion" is the more comprehensive and clinically accurate answer in the context of NEET-PG, as it encompasses both cerebellar and brainstem/craniocervical junction pathologies (like Syringobulbia or Chiari malformation). **High-Yield Clinical Pearls for NEET-PG:** * **Upbeat Nystagmus:** Usually indicates a lesion in the **medulla** or **midbrain**. * **Alexander’s Law:** Nystagmus of peripheral origin increases in intensity when looking in the direction of the fast phase. * **Central vs. Peripheral Nystagmus:** Central nystagmus is non-fatigable, lacks a latent period, and is not suppressed by visual fixation. * **Most common cause of Downbeat Nystagmus:** Arnold-Chiari Malformation (Type 1).

Q: What is the treatment for Benign Positional Vertigo?

Vestibular exercises. **Explanation:** **Benign Paroxysmal Positional Vertigo (BPPV)** is caused by the displacement of calcium carbonate crystals (otoconia) from the utricle into the semicircular canals (most commonly the posterior canal). **Why Option A is Correct:** The definitive treatment for BPPV is mechanical repositioning of these otoconia. **Vestibular exercises** and **Canalith Repositioning Maneuvers (CRMs)**, such as the **Epley maneuver** (for posterior canal) or **Semont maneuver**, are designed to move the debris out of the canal and back into the vestibule. For long-term habituation and balance retraining, **Brandt-Daroff exercises** are often prescribed. These physical interventions address the underlying mechanical cause, unlike pharmacological agents. **Why Other Options are Incorrect:** * **B & C (Vestibular sedatives/Antihistamines):** Drugs like Prochlorperazine, Cinnarizine, or Betahistine only suppress the symptoms (nausea/dizziness) but do not cure the condition. They may actually delay central compensation and are generally avoided in BPPV unless the patient is experiencing severe vomiting. * **D (Diuretics):** These are used in the management of **Meniere’s disease** to reduce endolymphatic hydrops, but they have no role in treating the mechanical displacement seen in BPPV. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** The **Dix-Hallpike Maneuver** (look for geotropic nystagmus with a latent period and fatigability). * **Most Common Canal:** Posterior Semicircular Canal. * **Epley Maneuver:** The treatment of choice for posterior canal BPPV. * **Key Differentiator:** BPPV presents with brief episodes of vertigo (seconds) triggered by head movement, with no hearing loss or tinnitus.

Q: All of the following assess vestibular function, except?

Lombard test. **Explanation:** The **Lombard test** is a test of **hearing (auditory function)**, not vestibular function. It is based on the "Lombard effect," where a person involuntarily increases the intensity of their voice when subjected to loud background noise. In clinical practice, it is used to detect **malingering** (pseudohypacusis). If a patient claims to have bilateral hearing loss but raises their voice when noise is introduced into their ears, it proves they can hear the noise. **Analysis of other options:** * **Fistula test:** Assesses the integrity of the bony labyrinth. A positive test (nystagmus/vertigo upon applying pressure to the EAC) indicates a **labyrinthine fistula**, commonly seen in cholesteatoma. * **Galvanic test:** Evaluates the **vestibular nerve** and central pathways. Unlike caloric tests (which only test the horizontal canal), the galvanic test bypasses the end organ to stimulate the nerve directly. * **VEMP (Vestibular Evoked Myogenic Potentials):** A modern electrophysiological test. **cVEMP** (cervical) assesses the **saccule** and inferior vestibular nerve, while **oVEMP** (ocular) assesses the **utricle** and superior vestibular nerve. **High-Yield Clinical Pearls for NEET-PG:** * **Caloric Test (COWS):** The most common test for the lateral semicircular canal. (Cold Opposite, Warm Same side nystagmus). * **Hennebert’s Sign:** A false positive fistula test (nystagmus without a fistula) seen in **Meniere’s disease** or **Congenital Syphilis** due to fibrous bands. * **Stenger’s Test:** Another high-yield test for **unilateral** malingering.

Q: The caloric test, which is based on thermal stimulation, primarily stimulates which part of the semicircular canals?

Lateral canal. **Explanation:** The **Caloric Test** (part of the Fitzgerald-Hallpike test) is a clinical assessment of the vestibulo-ocular reflex. It relies on the principle of **convection currents** induced by thermal stimulation (water or air) in the external auditory canal. **Why the Lateral Canal?** The lateral (horizontal) semicircular canal is the most superficial canal, lying in close proximity to the medial wall of the middle ear. During the test, the patient is positioned supine with the head tilted **30° forward**. This orientation places the lateral canal in a **vertical plane**. When cold or warm irrigation is applied, a temperature gradient is created across the canal, causing the endolymph to change density and move. This movement stimulates the hair cells in the crista ampullaris of the lateral canal specifically, triggering nystagmus. **Analysis of Incorrect Options:** * **A & B (Posterior and Anterior Canals):** These are the vertical canals. Due to their anatomical depth and orientation (even with head positioning), they are not significantly affected by the thermal gradient produced in the external ear canal. * **D (All Canals):** While theoretically, some heat might reach other structures, the caloric test is clinically validated and physiologically designed to isolate and test the **lateral canal** and its associated superior vestibular nerve. **High-Yield Clinical Pearls for NEET-PG:** * **COWS Mnemonic:** **C**old **O**pposite, **W**arm **S**ame (refers to the direction of the fast phase of nystagmus). * **Positioning:** Patient must be supine with the head at 30° to make the lateral canal vertical. * **Indication:** It is the gold standard for diagnosing **Unilateral Vestibular Hypofunction** (e.g., Canal Paresis in Meniere’s or Vestibular Neuronitis). * **Dead Labyrinth:** If no nystagmus occurs with both hot and cold stimulation, it indicates a non-functioning labyrinth.

Q: A 57-year-old banker complains of 2 days of severe dizziness. When she sits up or rolls over in bed, she has a spinning sensation that lasts for a few seconds and is followed by nausea. These episodes have occurred many times a day and prevent her from working. She denies fever or upper respiratory symptoms and takes no medications. When moved quickly from a sitting to a lying position with her head turned and hanging below the horizontal plane, she complains of dizziness, and horizontal nystagmus is noted. What is the most likely diagnosis?

Benign paroxysmal positional vertigo (BPPV). **Explanation:** The clinical presentation is classic for **Benign Paroxysmal Positional Vertigo (BPPV)**. The diagnosis is based on the triad of: 1. **Positional Triggers:** Vertigo occurs specifically during changes in head position (sitting up, rolling in bed). 2. **Short Duration:** Episodes last seconds to less than a minute. 3. **Positive Dix-Hallpike Maneuver:** The description of moving the patient from sitting to lying with the head hanging is the Dix-Hallpike maneuver, which elicits characteristic nystagmus and vertigo in BPPV patients. **Pathophysiology:** BPPV is caused by **canalithiasis**—dislodged otoconia (calcium carbonate crystals) from the utricle entering the semicircular canals (most commonly the **posterior canal**). **Why other options are incorrect:** * **Orthostatic Hypotension:** Presents as lightheadedness or syncope upon standing, not true rotatory vertigo triggered by rolling in bed. * **Meniere’s Disease:** Characterized by a triad of episodic vertigo (lasting 20 mins to hours), sensorineural hearing loss, and tinnitus/aural fullness. It is not typically triggered by brief head movements. * **Acoustic Neuroma (Vestibular Schwannoma):** Presents with progressive unilateral sensorineural hearing loss and equilibrium imbalance rather than acute, brief episodes of positional vertigo. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Dix-Hallpike Maneuver. * **Characteristic Nystagmus:** In posterior canal BPPV, nystagmus is **geotropic** (beats toward the ground), **rotatory/torsional**, and has a **latency** (starts after 2-5 seconds) and **fatigability** (decreases with repeat testing). * **Treatment of Choice:** Canalith repositioning maneuvers, specifically the **Epley Maneuver**. * **Most common canal involved:** Posterior Semicircular Canal (85-90%).

Q: Which of the following is NOT true about benign paroxysmal positional vertigo?

Good reproducibility. **Explanation:** Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause of peripheral vertigo, typically caused by canalolithiasis in the posterior semicircular canal. It is diagnosed using the **Dix-Hallpike Maneuver**. **Why "Good Reproducibility" is NOT true:** In BPPV, the characteristic nystagmus and vertigo show **poor reproducibility**. If the Dix-Hallpike maneuver is repeated multiple times in quick succession, the response becomes weaker or may not occur at all. This is due to the displacement and scattering of otoconia (calcium carbonate crystals) within the canal, making it harder to trigger the same neural response immediately. **Analysis of other options (Characteristics of BPPV):** * **Latency (D):** Vertigo and nystagmus do not start immediately. There is a delay of **5–20 seconds** after the head is moved into the provocative position. * **Fatigability (A) & Habituation (C):** These terms are often used interchangeably in this context. They refer to the phenomenon where the intensity of the nystagmus and vertigo **decreases with repeated testing**. This is a hallmark of peripheral vertigo (BPPV) and helps differentiate it from central causes of vertigo, which do not fatigue. **High-Yield Clinical Pearls for NEET-PG:** 1. **Most common canal involved:** Posterior Semicircular Canal (90%). 2. **Nystagmus pattern:** In posterior canal BPPV, the nystagmus is **geotropic** (beats toward the ground), **rotatory/torsional**, and **up-beating**. 3. **Treatment of choice:** **Epley’s Maneuver** (repositioning maneuver). For horizontal canal BPPV, the **Lempert (Barbecue) maneuver** is used. 4. **Duration:** Vertigo episodes typically last **less than one minute**.

Q: In Meniere's disease, all of the following are typically seen, EXCEPT:

Tinnitus and hearing loss decrease during an attack. **Explanation:** Meniere’s disease (Endolymphatic Hydrops) is characterized by an increase in the volume and pressure of the endolymph within the inner ear. **Why Option D is the Correct Answer (The "Except"):** In Meniere’s disease, an acute attack is triggered by a sudden increase in endolymphatic pressure. Consequently, **tinnitus and hearing loss significantly worsen (increase)** during an attack, rather than decrease. The classic triad includes episodic vertigo, fluctuating sensorineural hearing loss (SNHL), and roaring tinnitus, all of which peak during the symptomatic phase. **Analysis of Other Options:** * **Option A:** **Ballooning of Reissner’s membrane** is the hallmark histopathological finding. The increased endolymphatic pressure causes the membrane to bulge into the scala vestibuli. It may eventually rupture, leading to the mixing of endolymph and perilymph. * **Option B:** **Fluctuating hearing loss** is a defining clinical feature. Initially, the hearing loss involves low frequencies and improves between attacks, though it eventually becomes permanent and involves all frequencies (flat curve). * **Option C:** **Salt-restricted diet** is a primary conservative management strategy. Reducing sodium intake helps decrease endolymphatic pressure by reducing fluid retention. **High-Yield Clinical Pearls for NEET-PG:** * **Lermoyez Syndrome:** A variant where hearing actually *improves* during a vertigo attack (the "reverse" Meniere's). * **Audiometry:** Characteristically shows **Low-frequency SNHL** in early stages. * **Recruitment Phenomenon:** Present (indicates cochlear pathology). * **Glycerol Test:** Used for diagnosis; glycerol acts as an osmotic diuretic, temporarily improving hearing thresholds. * **Drug of Choice:** **Betahistine** is used for maintenance; Vestibular sedatives (e.g., Prochlorperazine) are used for acute attacks.

Question 1

Downbeat nystagmus is characteristic of which of the following?

Accepted Answer

Posterior fossa lesion

Answer

Vestibular lesion

Answer

Cerebellar lesion

Answer

Labyrinthine lesion

Question 2

What is the initial mechanism of action of intra-tympanic gentamicin delivered via a microwick catheter in the treatment of Meniere's disease?

Accepted Answer

Acts on melanoreceptors of outer hair cells

Answer

Damage to outer hair cells

Answer

Binds to hair cell Na*-K+ ATPase channel

Answer

Binds to Mg++ channel

Question 3

Tumarkin's crisis is said to be a variant of which of the following conditions?

Accepted Answer

Meniere's disease

Answer

Glue ear

Answer

Chronic suppurative otitis media (CSOM)

Answer

Otosclerosis

Question 4

What is the treatment for Benign Positional Vertigo?

Accepted Answer

Vestibular exercises

Answer

Vestibular sedatives

Answer

Antihistamines

Answer

Diuretics

Question 5

A patient with Meniere's disease has failed all medical treatment but still retains serviceable hearing. Which of the following treatments can be considered?

Accepted Answer

Labyrinthectomy

Answer

Endolymphatic sac decompression

Answer

Intratympanic gentamicin

Answer

Vestibular nerve section

Question 6

All of the following assess vestibular function, except?

Accepted Answer

Lombard test

Answer

Fistula test

Answer

Galvanic test

Answer

VEMP

Question 7

The caloric test, which is based on thermal stimulation, primarily stimulates which part of the semicircular canals?

Accepted Answer

Lateral canal

Answer

Posterior canal

Answer

Anterior canal

Answer

All semicircular canals

Question 8

A 57-year-old banker complains of 2 days of severe dizziness. When she sits up or rolls over in bed, she has a spinning sensation that lasts for a few seconds and is followed by nausea. These episodes have occurred many times a day and prevent her from working. She denies fever or upper respiratory symptoms and takes no medications. When moved quickly from a sitting to a lying position with her head turned and hanging below the horizontal plane, she complains of dizziness, and horizontal nystagmus is noted. What is the most likely diagnosis?

Accepted Answer

Benign paroxysmal positional vertigo (BPPV)

Answer

Orthostatic hypotension

Answer

Meniere disease

Answer

Acoustic neuroma

Question 9

Which of the following is NOT true about benign paroxysmal positional vertigo?

Accepted Answer

Good reproducibility

Answer

Fatigability

Answer

Habituation

Answer

Latency

Question 10

In Meniere's disease, all of the following are typically seen, EXCEPT:

Accepted Answer

Tinnitus and hearing loss decrease during an attack

Answer

Ballooning of the Reissner's membrane

Answer

Hearing loss is fluctuating in nature

Answer

Salt-restricted diet is advised

Vestibular Disorders — MCQs

Vestibular Disorders — MCQs

On this page

Practice by Chapter

Want unlimited practice?