Vestibular Disorders Practice Questions

Q: Vasodilators in Meniere's disease are useful because they:

Increase endolymph reabsorption. **Explanation:** Meniere’s disease is characterized by **endolymphatic hydrops**, which is an accumulation of excess endolymph within the inner ear. The primary goal of medical management is to reduce this pressure. **Why Option C is Correct:** The underlying pathophysiology involves either the overproduction of endolymph or, more commonly, its decreased absorption through the endolymphatic sac. **Vasodilators** (such as Betahistine or Nicotinic acid) are used because they improve microcirculation to the inner ear, specifically the **stria vascularis** and the **endolymphatic sac**. By increasing blood flow to these areas, they facilitate the **reabsorption of endolymph**, thereby reducing the hydrops and alleviating symptoms like vertigo and fullness. **Analysis of Incorrect Options:** * **Option A:** Dilating tympanic vessels affects the middle ear, not the inner ear (labyrinth) where the pathology of Meniere’s resides. * **Option B:** While some drugs (like Carbonic anhydrase inhibitors) may decrease secretion, the primary therapeutic mechanism of vasodilators in this context is enhancing the drainage/reabsorption pathway. * **Option C:** Vasodilators are a cornerstone of maintenance therapy in Meniere’s to reduce the frequency of attacks. **NEET-PG High-Yield Pearls:** * **Betahistine** is the most commonly used vasodilator (H1 agonist/H3 antagonist). * **Dietary management:** Low salt diet (<2g/day) is crucial to reduce hydrops. * **Classic Triad:** Episodic vertigo, Sensorineural hearing loss (fluctuating, low-frequency), and Tinnitus. * **Lermoyez Syndrome:** A variant where hearing improves during a vertigo attack (the "reverse" Meniere’s).

Q: All are features of Meniere's disease except:

Giddiness is provoked in certain head positions. ### Explanation Meniere’s disease (Endolymphatic Hydrops) is characterized by the distension of the endolymphatic system due to increased pressure. The diagnosis is primarily clinical, based on a classic tetrad of symptoms. **Why Option B is the Correct Answer (The "Except"):** Giddiness provoked by specific head positions is the hallmark of **Benign Paroxysmal Positional Vertigo (BPPV)**, not Meniere’s disease. In Meniere’s, vertigo occurs **spontaneously** and is episodic, typically lasting 20 minutes to several hours. It is not triggered by head movement, although movement may aggravate the sensation once an attack has already begun. **Analysis of Incorrect Options (Features of Meniere’s):** * **Option A (Fluctuating Hearing Loss):** Early in the disease, patients experience SNHL that improves between attacks. It characteristically involves **low frequencies** initially (ascending audiogram). * **Option C (Aural Fullness):** A sense of pressure or "fullness" in the affected ear often precedes or accompanies the vertigo attack. * **Option D (Roaring Tinnitus):** The tinnitus in Meniere’s is typically low-pitched and described as "roaring" or "seashell" like, often worsening during acute episodes. **High-Yield Clinical Pearls for NEET-PG:** * **Pathology:** Distension of Reissner’s membrane. * **Lermoyez Syndrome:** A variant where hearing *improves* during a vertigo attack. * **Tumarkin’s Otolithic Crisis:** Sudden "drop attacks" without loss of consciousness due to utriculo-saccular dysfunction. * **Recruitment Phenomenon:** Present in Meniere’s (indicates cochlear pathology). * **Glycerol Test:** Used for diagnosis; a positive test shows improvement in speech discrimination/audiometry after oral glycerol (osmotic dehydration).

Q: In the caloric test, cold water stimulation causes movement of the eye towards which side?

The opposite side. The caloric test is a clinical assessment of the vestibulo-ocular reflex (VOR) used to evaluate the function of the horizontal semicircular canal. ### **Explanation of the Correct Answer** The direction of the nystagmus (the fast phase) is traditionally remembered by the mnemonic **COWS**: **C**old **O**pposite, **W**arm **S**ame. When **cold water** is introduced into the external auditory canal, it cools the endolymph in the horizontal semicircular canal. This causes the endolymph to become denser and sink (convection current), leading to **ampullopetal** flow away from the ampulla. This inhibits the vestibular nerve on that side, causing a slow drift of the eyes toward the stimulated ear, followed by a corrective **fast phase (nystagmus) toward the opposite side.** ### **Explanation of Incorrect Options** * **Option A (Same side):** This occurs with **warm water** stimulation. Warm water causes the endolymph to rise, stimulating the nerve and producing a fast-phase nystagmus toward the same ear. * **Options C & D (Upwards/Downwards):** Caloric testing specifically stimulates the horizontal semicircular canal due to the patient’s positioning (head tilted 30° back). Vertical nystagmus usually indicates central vestibular lesions rather than peripheral canal stimulation. ### **High-Yield Clinical Pearls for NEET-PG** * **Patient Position:** The patient is supine with the head elevated at **30°** to bring the horizontal canal into a vertical plane. * **Water Temperatures:** Standard temperatures used are **30°C** (Cold) and **44°C** (Warm). * **Fitzgerald-Hallpike Test:** This is the formal name for the bithermal caloric test. * **Canal Paresis:** A reduction in response (usually >20-25% difference between sides) indicates a peripheral vestibular lesion, such as Meniere’s disease or Vestibular Schwannoma. * **Dead Labyrinth:** If no response is elicited even with ice-cold water, the labyrinth is considered non-functional.

Q: A 50-year-old female complains of an episode of acute vertigo with vomiting and unsteadiness and light-headedness, which was triggered by changing her head position in the morning. She denied hearing loss, recent viral illness, medication use, head injury, or trauma. Choose the most appropriate diagnosis:

BPPV. ### **Explanation: Benign Paroxysmal Positional Vertigo (BPPV)** The clinical presentation of **recurrent, brief episodes of vertigo triggered by head movements** (like rolling over in bed or getting up in the morning) without associated hearing loss is classic for **BPPV**. #### **Why BPPV is the Correct Answer** * **Mechanism:** It is caused by **canalolithiasis** (displaced otoconia, usually from the utricle into the **posterior semicircular canal**). * **Key Features:** Vertigo is **positional**, lasts for **seconds to minutes**, and is associated with autonomic symptoms like nausea/vomiting. * **Absence of "Red Flags":** The lack of hearing loss, tinnitus, or recent viral prodrome helps differentiate it from other vestibular disorders. #### **Why Other Options are Incorrect** * **Vestibular Neuritis:** Presents as a **prolonged, single episode** of severe vertigo (lasting days) often following a **viral upper respiratory infection**. It is not transiently triggered by head movement. * **Acoustic Neuroma:** A slow-growing tumor of the CN VIII. It typically presents with **progressive unilateral sensorineural hearing loss (SNHL)** and tinnitus rather than acute positional vertigo. * **Meniere Disease:** Characterized by a triad of **episodic vertigo (lasting 20 mins to hours)**, fluctuating SNHL, and **tinnitus/aural fullness**. #### **High-Yield Clinical Pearls for INI-CET** * **Gold Standard Diagnosis:** **Dix-Hallpike Maneuver** (look for geotropic, rotatory nystagmus with latency and fatigability). * **Treatment of Choice:** **Epley Maneuver** (Canalith Repositioning Procedure). * **Most Common Canal Involved:** **Posterior Semicircular Canal** (90% of cases). * **Nystagmus Characteristics:** In BPPV, the nystagmus is **paroxysmal** (starts after a few seconds) and **fatigable** (decreases with repeated testing).

Q: The following test is useful for diagnosis of?

It looks like you've provided an image of an audiologist performing a test on a patient, possibly an **electronystagmography (ENG)** or **videonystagmography (VNG)**, which are tests used to diagnose balance disorders. To provide a detailed explanation, I need the specific options for the question: "The following test is useful for diagnosis of?" Once you provide the options, I can explain: - **Why the correct option is suitable**, focusing on clinical features, test results, and associations. - **Why the incorrect options are unsuitable**, mentioning key differentiating features. Please provide the multiple-choice options.

Q: A 40-year-old woman presents with history of recurrent episodes of spinning sensation in horizontal direction with vertigo incapacitating her for hours and resolving with medication. She also report roaring tinnitus during the attacks. Her sequential audiogram done on 11.06.16 and 18.06.16 is given below. Diagnosis is:

Meniere's disease. ### ***Meniere's disease*** - This patient presents with the classic triad of **Meniere's disease**: recurrent **vertigo**, **roaring tinnitus**, and fluctuating **sensorineural hearing loss** (as shown by the sequential audiograms with improvement). - The audiogram demonstrates **fluctuating hearing loss**, which is typical for Meniere's, with the hearing loss being worse on June 11th and improving by June 18th, particularly at lower frequencies (a pattern often seen in Meniere's). ### *Migraine variant* - While migraine can cause vertigo (**vestibular migraine**), it typically does not present with characteristic **roaring tinnitus** or **fluctuating hearing loss** on audiometry. - The audiogram showing a clear pattern of fluctuating sensorineural hearing loss points away from an isolated migraine variant. ### *Benign paroxysmal positional vertigo* - BPPV causes **brief episodes of vertigo** triggered by specific head movements, usually lasting seconds to a minute, and is not associated with roaring tinnitus or hearing loss. - The patient's vertigo episodes are described as "incapacitating her for hours," which is inconsistent with the short duration of BPPV attacks. ### *Acoustic neuroma* - An acoustic neuroma typically causes **progressive, unilateral sensorineural hearing loss**, persistent tinnitus (often high-pitched), and sometimes imbalance, but **recurrent, sudden, severe vertigo** and **fluctuating hearing** are less common. - The rapid fluctuation and improvement in hearing shown on the sequential audiograms are not characteristic of the generally slow, progressive nature of hearing loss due to an acoustic neuroma.

Q: Which of the following test is being performed on the patient?

Dix-Hallpike test. ***Dix-Hallpike test*** - The image depicts a patient being moved from an upright sitting position to a supine position with the head turned to one side and extended, which is characteristic of the **Dix-Hallpike maneuver**. - This test is used to diagnose **benign paroxysmal positional vertigo (BPPV)** by provoking vertigo and nystagmus as a result of otoconia displacement in the semicircular canals. *Caloric stimulation test* - This test involves introducing **warm or cold water/air into the ear canal** to induce nystagmus, assessing the vestibular system. - It's typically performed with the patient lying supine with their head elevated at 30 degrees, not involving the specific positional changes shown in the image. *Doll's eye reflex* - Also known as the **oculocephalic reflex**, it assesses brainstem function by rapidly turning the patient's head while observing eye movement. - This reflex is primarily used to evaluate comatose patients and does not involve the complex body and head positioning seen in the image. *Frenzel maneuver* - The Frenzel maneuver is performed during **otoscopy** to check for nystagmus by having the patient gaze through high plus lenses in a dark room. - It is often used to suppress visual fixation and enhance nystagmus, but it does not involve the specific body or head movements depicted.

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

Head turned to right, corrective saccade to the left. ***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.

Q: A patient presents with vertigo, tinnitus, and head tilt. He underwent myringoplasty for the safe type of chronic suppurative otitis media (CSOM) 6 months back. What is your diagnosis?

Perilymphatic fistula. ***Perilymphatic fistula*** - The combination of **vertigo**, **tinnitus**, and **head tilt** occurring after a **myringoplasty**, even for a safe type of CSOM, suggests a perilymphatic fistula. - Myringoplasty can occasionally involve trauma to the **oval or round window**, leading to a direct communication between the inner ear (perilymph) and the middle ear, causing these symptoms. *Paget disease* - This is a **bone remodeling disorder** that primarily affects the skull, pelvis, and long bones, leading to bone pain and deformities. - While it can cause hearing loss (due to otosclerosis) and a sense of imbalance, it does not typically present with the acute onset of **vertigo** and **tinnitus** following ear surgery. *Labyrinthitis* - **Labyrinthitis** is an inflammation of the inner ear, typically caused by a viral infection, leading to sudden, severe **vertigo**, **nausea**, and often **hearing loss** or **tinnitus**. - While the symptoms of vertigo and tinnitus are present, the history of recent myringoplasty makes a **structural compromise** like a perilymphatic fistula a more specific diagnosis than generalized inflammation. *Vestibular schwannoma* - Also known as an acoustic neuroma, this is a **benign tumor** on the eighth cranial nerve, causing **gradual unilateral hearing loss**, **tinnitus**, and **imbalance**, but rarely sudden, intense vertigo unless very large. - The presentation with a history of myringoplasty and acute symptoms makes a **spontaneous structural defect** more likely than a slowly growing tumor.

Q: 35 years old female presents with tinnitus, vertigo and aural fullness. Likely diagnosis:

Meniere's Disease. ***Meniere's Disease*** - The classic triad of symptoms for Meniere's disease includes **tinnitus**, **vertigo**, and **aural fullness**, along with fluctuating sensorineural hearing loss. - This condition is thought to be caused by an excess of **endolymphatic fluid** within the inner ear. *Ototoxicity* - This condition typically presents with **bilateral, symmetrical hearing loss** and tinnitus, often induced by certain medications (e.g., aminoglycosides, aspirin in high doses). - It usually does not involve episodic vertigo or aural fullness, which are characteristic of Meniere's. *Noise Induced Hearing Loss* - Characterized primarily by **permanent sensorineural hearing loss**, often at specific frequencies (e.g., 4000 Hz notch), and **tinnitus** after prolonged exposure to loud noise. - It does not typically cause the episodic vertigo or sense of aural fullness seen in Meniere's disease. *Otosclerosis* - This condition causes **progressive conductive hearing loss** due to abnormal bone growth around the stapes bone, impairing its movement. - While it can cause tinnitus, it typically does not present with vertigo or aural fullness, and the primary hearing loss is conductive, not sensorineural.

Question 1

Vasodilators in Meniere's disease are useful because they:

Accepted Answer

Increase endolymph reabsorption

Answer

Dilate tympanic vessels

Answer

Decrease endolymph secretion

Answer

Are of no use

Question 2

All are features of Meniere's disease except:

Accepted Answer

Giddiness is provoked in certain head positions

Answer

Hearing loss that fluctuates

Answer

Sense of pressure or fullness in the ear

Answer

Roaring tinnitus

Question 3

In the caloric test, cold water stimulation causes movement of the eye towards which side?

Accepted Answer

The opposite side

Answer

The same side

Answer

Upwards

Answer

Downwards

Question 4

A 50-year-old female complains of an episode of acute vertigo with vomiting and unsteadiness and light-headedness, which was triggered by changing her head position in the morning. She denied hearing loss, recent viral illness, medication use, head injury, or trauma. Choose the most appropriate diagnosis:

Accepted Answer

BPPV

Answer

Vestibular neuritis

Answer

Acoustic neuroma

Answer

Meniere disease

Question 5

The following test is useful for diagnosis of?

Question 6

A 40-year-old woman presents with history of recurrent episodes of spinning sensation in horizontal direction with vertigo incapacitating her for hours and resolving with medication. She also report roaring tinnitus during the attacks. Her sequential audiogram done on 11.06.16 and 18.06.16 is given below. Diagnosis is:

Accepted Answer

Meniere's disease

Answer

Migraine variant

Answer

Benign paroxysmal positional vertigo

Answer

Acoustic neuroma

Question 7

Which of the following test is being performed on the patient?

Accepted Answer

Dix-Hallpike test

Answer

Caloric stimulation test

Answer

Doll's eye reflex

Answer

Frenzel maneuver

Question 8

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

Accepted Answer

Head turned to right, corrective saccade to the left

Answer

Head turned to left, corrective saccade to the right

Answer

Head turned to right, no corrective saccade

Answer

Head turned to left, no corrective saccade

Question 9

A patient presents with vertigo, tinnitus, and head tilt. He underwent myringoplasty for the safe type of chronic suppurative otitis media (CSOM) 6 months back. What is your diagnosis?

Accepted Answer

Perilymphatic fistula

Answer

Paget disease

Answer

Labyrinthitis

Answer

Vestibular schwannoma

Question 10

35 years old female presents with tinnitus, vertigo and aural fullness. Likely diagnosis:

Accepted Answer

Meniere's Disease

Answer

Ototoxicity

Answer

Noise Induced Hearing Loss

Answer

Otosclerosis

Vestibular Disorders — MCQs

Vestibular Disorders — MCQs

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