Vestibular Disorders Practice Questions

Q: A patient presents with episodic dizziness lasting 30-60 seconds, triggered by rolling over in bed and looking upward. Which test is most likely to confirm the diagnosis of benign paroxysmal positional vertigo?

Dix-Hallpike maneuver. ***Dix-Hallpike maneuver*** - The **Dix-Hallpike maneuver** is the gold standard for diagnosing **benign paroxysmal positional vertigo (BPPV)** by provoking vertigo and nystagmus characteristic of otoconia displacement in the semicircular canals. - This maneuver typically elicits **nystagmus** (rotatory and upbeating) that has a latency of a few seconds and fatigues quickly, which is highly indicative of **BPPV**. *Rinne test* - The **Rinne test** is used to assess **conductive** versus **sensorineural hearing loss** by comparing air and bone conduction, not vertigo. - A normal Rinne test shows **air conduction** better than **bone conduction**. *Weber test* - The **Weber test** also evaluates **hearing loss** by placing a vibrating tuning fork on the patient's forehead, determining if sound lateralizes to one ear. - It helps differentiate between **conductive** and **sensorineural hearing loss** laterally. *Electronystagmography* - While **electronystagmography (ENG)** assesses eye movements and nystagmus to identify vestibular disorders, it is not specific for diagnosing BPPV. - ENG can detect central or peripheral vestibular dysfunction but does not directly provoke the specific nystagmus seen in BPPV during positional changes.

Q: Identify the maneuver depicted in the image.

Epley maneuver. ***Epley*** - The image depicts the characteristic sequence of head and body positions used in the **Epley maneuver**, designed to reposition otoconia from the posterior semicircular canal. - Key steps include head rotation to the affected side (A, B), rapid recline with head hanging (B), sequential rotations (C, D), and sitting upright (E) to guide the particles out. *Foster maneuver* - The **Foster maneuver (or half somersault maneuver)** typically involves kneeling and tucking the head, then slowly elevating it through specific positions, which is not shown in the image. - It is often used for **benign paroxysmal positional vertigo (BPPV)** affecting the posterior canal, but its steps are distinct from those pictured. *Semont maneuver* - The **Semont maneuver** involves rapid movement from lying on one side to lying on the opposite side, with the head turned in a specific direction. - This maneuver is characterized by **abrupt positional changes**, differing from the more gradual and controlled head movements shown in the image. *Brandt-Daroff maneuver* - The **Brandt-Daroff maneuver** involves repeatedly moving from an upright sitting position to a side-lying position, holding each position for about 30 seconds. - It is a **habituation exercise** that patients can perform at home, and its steps do not match the specific sequence and assisted movements illustrated.

Q: Which semicircular canal is most commonly involved in BPPV?

Posterior. ***Correct Option: Posterior*** - The **posterior semicircular canal** is most commonly affected in **Benign Paroxysmal Positional Vertigo (BPPV)**, accounting for approximately **80-90% of cases**. - Its **gravity-dependent anatomical position** allows for the accumulation of displaced otoconia (calcium carbonate crystals) from the utricle more readily. - This anatomical configuration makes it the most susceptible canal for canalithiasis. *Incorrect: Horizontal* - While the **horizontal (lateral) canal** can be involved in BPPV, it accounts for only **10-20% of cases**, making it less common than the posterior canal. - **Horizontal canal BPPV** typically presents with different nystagmus characteristics, such as **geotropic or apogeotropic horizontal nystagmus** depending on whether it's canalithiasis or cupulolithiasis. *Incorrect: Superior* - Involvement of the **superior (anterior) semicircular canal** in BPPV is very rare, occurring in **less than 2-3% of cases**. - When it does occur, it presents with specific diagnostic features including **downbeat nystagmus** during provocative maneuvers. *Incorrect: All of the options* - Although BPPV can theoretically affect any of the semicircular canals, they are **not equally affected**. - The **posterior canal** is overwhelmingly the most common site (~80-90%), followed by horizontal (~10-20%), with superior canal involvement being rare (<3%). - Therefore, stating "all of the options" as the most commonly involved canal is incorrect.

Q: What condition is primarily detected using illuminated Frenzel glasses?

Nystagmus. ***Nystagmus*** - Illuminated Frenzel glasses **prevent visual fixation** and magnify the eyes, thereby unmasking and enhancing the observation of nystagmus. - This allows for the detection of subtle or latent nystagmus that might be suppressed by visual fixation in a normal examination. *Heterophoria* - Heterophoria is a **latent deviation of the eyes** that is only apparent when fusion is broken. - While Frenzel glasses prevent fixation, they are primarily used to observe eye movements, not specifically to measure or diagnose heterophoria, which is typically found using **cover-uncover tests** or other specialized techniques. *Esotropia* - Esotropia is a type of **strabismus** where one or both eyes turn inward. - This condition is typically visible on gross inspection or can be confirmed with **cover-uncover tests** or other objective measures of ocular alignment, not primarily with Frenzel glasses. *Astigmatism* - Astigmatism is an optical defect that results in blurred vision due to the inability of the eye to focus light equally on the retina across different axes. - It is diagnosed by **refraction methods** using an autorefractor, retinoscopy, or subjective refraction, not by observing eye movements with Frenzel glasses.

Q: What does a positive head impulse test suggest?

Injury to peripheral vestibular nerve. Injury to peripheral vestibular nerve - A positive head impulse test (HIT) indicates a deficit in the vestibulo-ocular reflex (VOR), specifically due to a problem with the peripheral vestibular system. - When the head is quickly turned towards the affected side, the eyes cannot maintain their gaze on the target, resulting in a corrective saccade back to the target object. Injury to the vestibular nuclei - Dysfunction of the vestibular nuclei ( central vestibular system) typically presents with a negative head impulse test, as the peripheral afferent input to the VOR arc is intact. - Central lesions are more likely to cause other signs like vertical nystagmus or other neurological deficits [2]. Lesion in the brainstem - A brainstem lesion is a problem in the central nervous system, which usually results in a negative head impulse test. - Brainstem involvement is often associated with other neurological signs, such as diplopia, dysarthria, or hemiparesis, not typically isolated VOR dysfunction [2]. Injury to the oculomotor nerve - An oculomotor nerve (cranial nerve III) injury primarily affects eye movements, causing ptosis, mydriasis, and inability to move the eye medially, supra, or infra [1]. - It does not directly affect the vestibular system or the reflexive eye movements tested by the head impulse test, which assesses the connection between head movement and eye movement.

Q: Identify the maneuver shown in the image.

Epley. ***Epley*** - The image displays the classic sequence of head and body movements characteristic of the **Epley maneuver**, designed to reposition otoconia from the semicircular canals back into the utricle. - This maneuver involves a series of specific head turns and body positions, often starting in an upright seated position, then lying down while turning the head, and rotating the body, as depicted. *Brandt daroff* - The **Brandt-Daroff exercises** involve rapid, self-administered movements between sitting and lying on one side, then sitting up and lying on the other side. - These exercises are typically performed multiple times a day and differ in their sequence from the repositioning maneuvers shown. *Foster* - The **Foster maneuver**, also known as the "half-somersault maneuver," is a self-administered variant used for posterior canal BPPV, particularly when the Epley maneuver is difficult to perform. - It involves beginning in a kneeling position, looking up, placing the head on the floor, and tucking the chin, which is distinct from the sequence shown. *Semont* - The **Semont maneuver** involves rapid movement from a sitting position to lying on one side with the head turned up, then rapidly moving to lie on the opposite side with the head turned down. - While it is a repositioning maneuver for BPPV, its specific rapid movements and head orientations differ from those illustrated in the image.

Q: A patient with ear complaints showed positive Hennebert sign. Which of the following conditions shows positive Hennebert sign?

Meniere's disease. ***Meniere's disease*** - The **Hennebert sign** involves nystagmus and vertigo induced by positive or negative pressure in the external auditory canal, indicating abnormal communication between the middle and inner ear. - While **congenital syphilis** and **perilymphatic fistula** are the classic associations with Hennebert sign, it can also occur in **Meniere's disease** due to increased endolymphatic pressure and membrane abnormalities. - In Meniere's disease, the sign may be related to **distention of the endolymphatic system** causing abnormal response to pressure changes in the external canal. - Among the options provided, Meniere's disease is the condition that can demonstrate a positive Hennebert sign. *Acoustic neuroma* - This condition presents with **unilateral progressive hearing loss**, tinnitus, and balance issues, but does not typically cause a positive Hennebert sign. - An acoustic neuroma is a **benign tumor** (vestibular schwannoma) that compresses the vestibulocochlear nerve, not directly affecting pressure sensitivity of the labyrinth. - The tumor causes symptoms through **compression** rather than through abnormal pressure transmission mechanisms. *Vestibular neuronitis* - Characterized by **sudden onset of severe vertigo** without hearing loss, caused by inflammation of the vestibular nerve. - Does not involve pressure-induced nystagmus or abnormal middle-inner ear communication. - Diagnosis is made clinically based on acute **vertigo**, **absence of auditory symptoms**, and normal ear examination. *Glossopharyngeal neuralgia* - This is a **cranial nerve IX disorder** causing severe, stabbing pain in the throat, tongue, ear, and tonsil area, completely unrelated to vestibular function. - The pain is triggered by specific actions like **swallowing**, **coughing**, or **touching the tonsils**. - Has no association with the Hennebert sign or vestibular pressure phenomena.

Q: Chemical labyrinthectomy by transtympanic route is done in Meniere's disease using which drug?

Gentamicin. ***Gentamicin*** - **Gentamicin** is an **aminoglycoside antibiotic** that is commonly used for chemical labyrinthectomy due to its **ototoxic** properties, particularly its selective toxicity to **vestibular hair cells** at lower doses. - When administered transtympanically, it achieves high concentrations in the **inner ear fluid**, effectively ablating the vestibular function and reducing severe vertigo in **Meniere's disease**. *Amikacin* - **Amikacin** is also an **aminoglycoside antibiotic** with ototoxic potential, but it is typically reserved for severe bacterial infections and is not the primary drug of choice for **chemical labyrinthectomy** in Meniere's disease. - While it can cause hearing loss, **gentamicin** has a more established and preferential effect on the **vestibular system** at therapeutic doses for Meniere's. *Amoxycillin* - **Amoxycillin** is a common **beta-lactam antibiotic** used for bacterial infections, and it does not possess **ototoxic** properties that would make it suitable for chemical labyrinthectomy. - It is primarily known for its antibacterial action and has no role in the management of vertigo in **Meniere's disease** via transtympanic administration. *Cyclosporine* - **Cyclosporine** is an **immunosuppressant drug** used to prevent organ rejection and treat autoimmune conditions; it does not have properties for chemical ablation of the labyrinth. - While some autoimmune components are sometimes considered in Meniere's disease, cyclosporine is not used for **transtympanic chemical labyrinthectomy**.

Q: Which of the following tests is specifically used to assess vestibular function?

Caloric test. ***Caloric test*** - The caloric test assesses the function of the **horizontal semicircular canal** and its associated neural pathways by introducing warm or cold water/air into the ear canal. - It induces nystagmus and vertigo, allowing for evaluation of the **vestibular reflex arc**. *Fistula test* - The fistula test assesses for a **perilymphatic fistula**, an abnormal connection between the middle and inner ear, which is a specific cause of vestibular dysfunction. - While related to vestibular function, it tests for a **structural defect** rather than directly assessing overall vestibular response. *Dix-Hallpike maneuver* - The Dix-Hallpike maneuver is used to diagnose **Benign Paroxysmal Positional Vertigo (BPPV)** by provoking positional nystagmus and vertigo. - It assesses for **otoconia displacement** within the semicircular canals but is not a general test of overall vestibular function. *All of the options* - While all listed tests relate to the ear and balance, only the **caloric test** is considered a foundational and specific assessment of the vestibular system's response to thermal stimulation. - The Dix-Hallpike and fistula tests investigate specific conditions or structural defects rather than a broad evaluation of vestibular end-organ function.

Question 1

A patient presents with episodic dizziness lasting 30-60 seconds, triggered by rolling over in bed and looking upward. Which test is most likely to confirm the diagnosis of benign paroxysmal positional vertigo?

Accepted Answer

Dix-Hallpike maneuver

Answer

Rinne test

Answer

Weber test

Answer

Electronystagmography

Question 2

Identify the maneuver depicted in the image.

Accepted Answer

Epley maneuver

Answer

Foster maneuver

Answer

Semont maneuver

Answer

Brandt-Daroff maneuver

Question 3

Which semicircular canal is most commonly involved in BPPV?

Accepted Answer

Posterior

Answer

Horizontal

Answer

Superior

Answer

All of the options

Question 4

What condition is primarily detected using illuminated Frenzel glasses?

Accepted Answer

Nystagmus

Answer

Heterophoria

Answer

Esotropia

Answer

Astigmatism

Question 5

What does a positive head impulse test suggest?

Accepted Answer

Injury to peripheral vestibular nerve

Answer

Injury to the vestibular nuclei

Answer

Lesion in the brainstem

Answer

Injury to the oculomotor nerve

Question 6

Identify the maneuver shown in the image.

Accepted Answer

Epley

Answer

Brandt-Daroff

Answer

Foster

Answer

Semont

Question 7

A patient with ear complaints showed positive Hennebert sign. Which of the following conditions shows positive Hennebert sign?

Accepted Answer

Meniere's disease

Answer

Glossopharyngeal neuralgia

Answer

Acoustic neuroma

Answer

Vestibular neuronitis

Question 8

Chemical labyrinthectomy by transtympanic route is done in Meniere's disease using which drug?

Accepted Answer

Gentamicin

Answer

Amikacin

Answer

Amoxycillin

Answer

Cyclosporine

Question 9

Endolymphatic sac decompression is done in?

Accepted Answer

Definitive treatment for intractable vertigo in Meniere's disease

Answer

Management of endolymphatic hydrops in early-stage Meniere's disease

Answer

Prophylactic treatment in recurrent vertigo syndromes

Answer

Primary surgical approach for cochlear disorders

Question 10

Which of the following tests is specifically used to assess vestibular function?

Accepted Answer

Caloric test

Answer

Fistula test

Answer

Dix-Hallpike maneuver

Answer

All of the options

Vestibular Disorders — MCQs

Vestibular Disorders — MCQs

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