Vertigo

Vertigo

Q. 1 Clinical features of a vertebrobasilar transient ischemic attack include all the following except:
 A ‘Drop’ attacks
 B Aphasia
 C Diplopia & vertigo
 D Ataxia
Q. 1 Clinical features of a vertebrobasilar transient ischemic attack include all the following except:
 A ‘Drop’ attacks
 B Aphasia
 C Diplopia & vertigo
 D Ataxia
Ans. B

Explanation:

Aphasia

A vertebrobasilar transient ischemic attack is characterized by the sudden onset of one or the more of the following symptoms and signs .Paresis (1,2 or 4/limbs), drop attacks, numbness of involved limbs and face, impaired vision (Diplopia or Bilateral visual field defects) vertigo, nausea, dysarthria and ataxia. Aphasia is a feature of Carotid artery transient ischemic attack.


Q. 2

Epley’s test is used for__________

 A

Benign paroxysmal vertigo

 B

Basilar migraine

 C

Orthostatic hypotension

 D

Thoracic outlet syndrome

Q. 2

Epley’s test is used for__________

 A

Benign paroxysmal vertigo

 B

Basilar migraine

 C

Orthostatic hypotension

 D

Thoracic outlet syndrome

Ans. A

Explanation:

 

Benign paroxysmal positional vertigo (BPPV):

  • It is characterised by vertigo when the head is placed in a certain critical position. There is no hearing loss or other neurologic symptoms.
  • Disease is caused by a disorder of posterior semicircular canal though many patients have history of head trauma and ear infection
  • It has been demonstrated that otoconial debris, consisting of crystals of calcium carbonate, is released from the degenerating macula of the utricle and floats freely in the endolymph
  • The condition can be treated by performing Epley’s manoeuvre. The principle of this manoeuvre is to reposition the otoconial debris from the posterior semicircular canal back into the utricle.
  • The manoeuvre consists of five positions.
  1. Position 1; With the head turned 45°, the patient is made to lie down in head-hanging position (DixHallpike manoeuvre). It will cause vertigo and nystagmus. Wait till vertigo and nystagmus subside.
  2. Position 2. Head is now turned so that affected ear is up.
  3. Position 3. The whole body and head are now rotated away from the affected ear to a la teral recumbent position in a face-down position.
  4. Position 4. Patient is now brought to a Sitting posiition with head st ill turned to the unaffected side by 45°
  5. Position 5. The head is now turned forward and chin brought down 20°.

Q. 3

An adolescent female has headache which is intermittent in episode in associated with tinnitus, vertigo and hearing loss. There is history of similar complains in her mother. Most likely diagnosis 

 A

Basilar migraine

 B

Cervical spondylosis

 C

Temporal arteritis

 D

Vestibular neuronitis

Q. 3

An adolescent female has headache which is intermittent in episode in associated with tinnitus, vertigo and hearing loss. There is history of similar complains in her mother. Most likely diagnosis 

 A

Basilar migraine

 B

Cervical spondylosis

 C

Temporal arteritis

 D

Vestibular neuronitis

Ans. A

Explanation:

Basilar migraine [Ref: CMDT 09 p. 849]

  • It is a case of Basilar migraine
  • Since it was believed to have originated in the basilar artery it was earlier called basilar artery migraine, but the absence of consistent evidence for basilar artery involvement lead to renaming as Basilar migraine only.
  • Basilar migraine is characterized by aura comprising of a bewildering variety of signs and symptoms of the visual cortex and brain stem.

– Basilar migraine mimicks ischemic strokes of the brainstem and the posterior cortical regions.

  • The aura which lasts for 10-45 minutes usually begin with typical migrainous disturbance of vision and is characterized by : ?

– Visual symptoms in both the temporal and nasal, fields.

– Dysorthria

– Vertigo

– Tinnitus

– Decreased hearing

– Double vision

– Ataxia

– B/L paresthesia

B/L paresis

– Decreased level of consciousness

  • After the aura is over a severe throbbing occipital headache supervenes.

Q. 4

A clinical condition seen in a 24 year old male is characterised by a facial palsy and is often associated with facial pain and the appearance of vesicles on the canal and pinna. Vertigo and sensor neural hearing loss (VIIIth nerve) accompanying it is suggestive of:

 A

Downs Syndrome

 B

Bells Palsy

 C

Pendred Syndrome

 D

Ramsay Hunt Syndrome

Q. 4

A clinical condition seen in a 24 year old male is characterised by a facial palsy and is often associated with facial pain and the appearance of vesicles on the canal and pinna. Vertigo and sensor neural hearing loss (VIIIth nerve) accompanying it is suggestive of:

 A

Downs Syndrome

 B

Bells Palsy

 C

Pendred Syndrome

 D

Ramsay Hunt Syndrome

Ans. D

Explanation:

Q. 5

All are TRUE about the clinical features of polycythemia rubra vera, EXCEPT:

 A

Hepatomegaly is the initial presenting sign

 B

Aquagenic pruritus present

 C

Vertigo, tinnitus, headache and visual disturbances are due to hyperviscosity

 D

Systolic hypertension is a feature of increased red cell mass

Q. 5

All are TRUE about the clinical features of polycythemia rubra vera, EXCEPT:

 A

Hepatomegaly is the initial presenting sign

 B

Aquagenic pruritus present

 C

Vertigo, tinnitus, headache and visual disturbances are due to hyperviscosity

 D

Systolic hypertension is a feature of increased red cell mass

Ans. A

Explanation:

Polycythemia rubra vera clinical features:
  • Splenomegaly may be the initial presenting sign 
  • Aquagenic pruritus
  • Hyperviscosity leads to vertigo, tinnitus, headache, visual disturbances, and transient ischemic attacks (TIAs). 
  • Systolic hypertension is due to red cell mass elevation. 
  • Venous or arterial thrombosis may be the presenting manifestation of PV. 
  • Erythromelalgia, is a complication of the thrombocytosis
  • Hyperuricemia with secondary gout, uric acid stones, and symptoms due to hypermetabolism can also complicate the disorder.
Ref: Harrison, E-18, P-899

Q. 6

A young girl presents with repeated episodes of throbbing occipital headache associated with ataxia and vertigo. The family history is positive for similar headaches in her mother. Most likely diagnosis is:

 A

Vestibular Neuronitis

 B

Basilar migraine

 C

Cluster headache

 D

Tension headache

Q. 6

A young girl presents with repeated episodes of throbbing occipital headache associated with ataxia and vertigo. The family history is positive for similar headaches in her mother. Most likely diagnosis is:

 A

Vestibular Neuronitis

 B

Basilar migraine

 C

Cluster headache

 D

Tension headache

Ans. B

Explanation:

It mainly occurs in young females and children, frequently in context with a family history of other forms of migraine.

It clinically manifests with bilateral visual symptoms associated with vertigo, ataxia, tinnitus.

Weakness and peripheral dysaesthesias and sometimes other brainstem and occipital lobe symptoms.

This is followed by severe, throbbing, posterior bilateral headache.

Ref: Benign childhood partial seizures and related epileptic syndromes — Chrysostomos P. Panayiotopoulos, Page 304


Q. 7

A fifty-year-old man presents to his practitioner 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 diagnosis?

 A

Benign paroxysmal positional vertigo

 B

Brain stem tumor

 C

Meniere’s disease

 D

Syncope

Q. 7

A fifty-year-old man presents to his practitioner 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 diagnosis?

 A

Benign paroxysmal positional vertigo

 B

Brain stem tumor

 C

Meniere’s disease

 D

Syncope

Ans. A

Explanation:

Benign paroxysmal positional vertigo (BPPV) is vertigo that is precipitated by head position. It can be precipitated by trauma, but often no precipitating factor is identified. It generally abates after weeks to months. On exam, patients display nystagmus and the symptoms can be reproduced by head movement. In addition, the symptoms show latency, fatigability and habituation.

Brain stem tumor and vertebrobasilar TIA are causes of central causes of vertigo, but would often be associated with other neurologic findings.
 
Meniere disease displays the classic triad of unilateral tinnitus, unilateral deafness, and paroxysmal vertigo. Since the patient has normal hearing, this is unlikely to be Meniere syndrome, although hearing loss may not manifest until later stages of the disease.
 
Syncope is defined as transient loss of consciousness of cardiovascular origin. Thus since the patient has a lack of other cardiovascular symptoms and has not lost consciousness, this is not syncope.

Q. 8

Epley’s test is used for which of the following conditions?

 A

Benign paroxysmal positional vertigo

 B

Basilar migraine

 C

Orthostatic hypotension

 D

Thoracic outlet syndrome

Q. 8

Epley’s test is used for which of the following conditions?

 A

Benign paroxysmal positional vertigo

 B

Basilar migraine

 C

Orthostatic hypotension

 D

Thoracic outlet syndrome

Ans. A

Explanation:

Benign paroxysmal positional vertigo (BPPV) is characterised by vertigo when the head is placed in a certain critical position.

There is no hearing loss or other neurologic symptoms. Disease is caused by a disorder of posterior semicircular canal.

The condition can be treated by performing Epley’s manoeuvre.

The principle of this manoeuvre is to reposition the otoconial debris from the posterior semicircular canal back into the utricle.


Q. 9

A fifty-year-old man presents to his practitioner 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 diagnosis?

 A

Benign paroxysmal positional vertigo

 B

Brain stem tumor

 C

Meniere’s disease

 D

Syncope

Q. 9

A fifty-year-old man presents to his practitioner 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 diagnosis?

 A

Benign paroxysmal positional vertigo

 B

Brain stem tumor

 C

Meniere’s disease

 D

Syncope

Ans. A

Explanation:

Benign paroxysmal positional vertigo (BPPV) is vertigo that is precipitated by head position. It can be precipitated by trauma, but often no precipitating factor is identified. It generally abates after weeks to months. On exam, patients display nystagmus and the symptoms can be reproduced by head movement. In addition, the symptoms show latency, fatigability and habituation.

Brain stem tumor and vertebrobasilar TIA are causes of central causes of vertigo, but would often be associated with other neurologic findings.
 
Meniere disease displays the classic triad of unilateral tinnitus, unilateral deafness, and paroxysmal vertigo. Since the patient has normal hearing, this is unlikely to be Meniere syndrome, although hearing loss may not manifest until later stages of the disease.
 
Syncope is defined as transient loss of consciousness of cardiovascular origin. Thus since the patient has a lack of other cardiovascular symptoms and has not lost consciousness, this is not syncope.

Q. 10

Triad of tinnitus, progressive deafness and vertigo along with facial weakness is seen in which of the following conditions?

 A

Meniere’s disease

 B

Lermoyez syndrome

 C

Acoustic neuroma

 D

Otosclerosis

Q. 10

Triad of tinnitus, progressive deafness and vertigo along with facial weakness is seen in which of the following conditions?

 A

Meniere’s disease

 B

Lermoyez syndrome

 C

Acoustic neuroma

 D

Otosclerosis

Ans. C

Explanation:

Acoustic neuroma arise from the nerve sheath cells of the acoustic nerve in the region of the internal auditory meatus. The symptoms of this condition includes progressive unilateral sensorineural deafness, tinnitus and vertigo. At the cerebellopontine angle it puts pressure on  ipsilateral cranial nerves and can produce facial palsy and trigeminal nerve involvement.
 
Causes of vertigo in different diseases:
  • Vertigo precipitated by the movement of head in a specific direction: Benign positional vertigo.
  • Intermittent brief vertigo with occasional drop attacks, ataxia, visual loss, double vision and confusion:  Vertebrobasilar insufficiency.
  • Episodic recurrent vertigo, with auditory symptoms, headache, photophobia and aura: Migraine.
  • Vertigo with facial weakness and loss  of taste sensation: Ramsay hunt syndrome.
  • Triad of episodic vertigo, tinnitus and progressive deafness: Meniere’s disease.


Q. 11

A patient on total parenteral nutrition for 20 days presents with weakness, vertigo and convulsions. Diagnosis is:

 A

Hypomagnesemia

 B

Hyperammonemia

 C

Hypercalcemia

 D

Hyperkalemia

Q. 11

A patient on total parenteral nutrition for 20 days presents with weakness, vertigo and convulsions. Diagnosis is:

 A

Hypomagnesemia

 B

Hyperammonemia

 C

Hypercalcemia

 D

Hyperkalemia

Ans. A

Explanation:

Ans. is ‘a’ i.e., Hypomagnesemia

All the above given metabolic abnormalities except hyperammonemia is seen in TPN, however the symptoms mentioned match with those of hypomagnesemia.


Q. 12

Post traumatic vertigo is due to:

 A

Perilymphatic fistula

 B

Vestibular neuritis

 C

Secondary endolymphatic hydrops

 D

a and c

Q. 12

Post traumatic vertigo is due to:

 A

Perilymphatic fistula

 B

Vestibular neuritis

 C

Secondary endolymphatic hydrops

 D

a and c

Ans. D

Explanation:

Q. 13

Postitional vertigo is:

 A

Lateral

 B

Superior

 C

Inferior

 D

Posterior

Q. 13

Postitional vertigo is:

 A

Lateral

 B

Superior

 C

Inferior

 D

Posterior

Ans. D

Explanation:

Q. 14

What is the treatment for Benign Positional vertigo?

 A

Vestibular exercises

 B

Vestibular sedatives

 C

Anthistamines

 D

Diuretics

Q. 14

What is the treatment for Benign Positional vertigo?

 A

Vestibular exercises

 B

Vestibular sedatives

 C

Anthistamines

 D

Diuretics

Ans. A

Explanation:

Q. 15

Vertigo is defined as:

 A

Subjective sense of imbalance

 B

Objective sense of imbalance

 C

Both of the above

 D

Round movement

Q. 15

Vertigo is defined as:

 A

Subjective sense of imbalance

 B

Objective sense of imbalance

 C

Both of the above

 D

Round movement

Ans. A

Explanation:

Q. 16

Positional vertigo is due to stimulation of:

 A

Lateral semicircular canal

 B

Superior semicircular canal

 C

Inferior semicircular canal

 D

Posterior semicircular canal

Q. 16

Positional vertigo is due to stimulation of:

 A

Lateral semicircular canal

 B

Superior semicircular canal

 C

Inferior semicircular canal

 D

Posterior semicircular canal

Ans. D

Explanation:

Q. 17

Epleys maneuver is done in:

 A

Positional vertigo

 B

Otosclerosis

 C

ASOM

 D

CSOM

Q. 17

Epleys maneuver is done in:

 A

Positional vertigo

 B

Otosclerosis

 C

ASOM

 D

CSOM

Ans. A

Explanation:

Ans. is a i.e. Positional vertigo 

Benign paroxysmal positional vertigo (BPPV) is characterised by vertigo when the head is placed in a certain critical postion, and can be treated by Epley’s maneuver.

The principle of this maneuver is to reposition the otoconial debris from the posterior semicircular canal back into the utricle. After maneuver is complete, patient should maintain an upright posture for 48 hour. Eighty per cent of the patients will be cured by a single maneuver.


Q. 18

A young girl presents with repeated episodes of throbbing occipital headache associated with ataxia and vertigo. The family history is positive for similar headaches in her mother. Most likely diagnosis is:

 A

Vestibular Neuronitis

 B

Basilar migraine

 C

Cluster headache

 D

Tension headache

Q. 18

A young girl presents with repeated episodes of throbbing occipital headache associated with ataxia and vertigo. The family history is positive for similar headaches in her mother. Most likely diagnosis is:

 A

Vestibular Neuronitis

 B

Basilar migraine

 C

Cluster headache

 D

Tension headache

Ans. B

Explanation:

Answer. is B (Basilar migraine)

Repeated episodes of throbbing occipital headache in association with ataxia and vertigo in a young female with a positive family history of headache suggest a diagnosis of basilar migraine.

Dizziness, vertigo and ataxia heralding an intense throbbing (occipital) headache are typical features of basilar type migraine

Diagnosis of Basilar Migraine is suggested by age, female gender, positive family history and attacks of headache with vertiginous aura provoked by usual migraine triggers

Basilar Type Migraine (subtype of migraine with aura)

  • Basilar type migraine describes recurrent attacks of migraine with aura in which symptoms suggest a brainstem origin (including vertigo & ataxia)
  • The onset of Basilar type migraine is typically before 30 years of age and peaks during adolescence
  • There is a distinct female preponderance with girls more frequently affected than boys in a ratio of 3:1 (majority of sufferers are girls )
  • Family history of migraine is frequent
  • Unlike other types of migraine headache may be occipital in origin
Reference:

‘Vertigo & Disequilibrium: A practical guide to diagnosis and management’ by Weber (Thieme); ‘Handbook of Headache (Lippincott- Williams)’ 2nd/214

Practical Neurology’ by Biller 3rd/15


Q. 19

All of the following are true for Vogt-Koyanagi­Harada syndrome except:

 A

More common in Japanese people, who are usually positive for HLA-B27

 B

Ocular features are; Chronic granulomatous anterior uveitis, posterior uveitis and exudative retinal detachment

 C

Cutaneous lesions are alopecia, poliosis and vitiligo

 D

Neurological lesions include, meningism, encephalopathy, tinnitis, vertigo and deafness

Q. 19

All of the following are true for Vogt-Koyanagi­Harada syndrome except:

 A

More common in Japanese people, who are usually positive for HLA-B27

 B

Ocular features are; Chronic granulomatous anterior uveitis, posterior uveitis and exudative retinal detachment

 C

Cutaneous lesions are alopecia, poliosis and vitiligo

 D

Neurological lesions include, meningism, encephalopathy, tinnitis, vertigo and deafness

Ans. A

Explanation:

Ans. More common in Japanese people, who are usually positive for HLA-B27


Q. 20

Which of ‘.he following defines vertigo:

September 2011

 A

Ringing of ears

 B

Subjective sense of imbalance

 C

Sense of pressure in the ear

 D

Infection of the inner ear

Q. 20

Which of ‘.he following defines vertigo:

September 2011

 A

Ringing of ears

 B

Subjective sense of imbalance

 C

Sense of pressure in the ear

 D

Infection of the inner ear

Ans. B

Explanation:

Ans. B: Subjective sense of imbalance

In vertigo, patient gets a feeling of rotation of himself or of his environment.

Vertigo (“a whirling or spinning movement”)

  • It is a type of dizziness, where there is a feeling of motion when one is stationary.
  • The symptoms are due to a dysfunction of the vestibular system in the inner ear.
  • It is often associated with nausea and vomiting as well as difficulties standing or walking.
  • The most common causes are benign paroxysmal positional vertigo, concussion and vestibular migraine while less common causes include Meniere’s disease and vestibular neuritis.
  • Excessive consumption of ethanol (alcoholic beverages) can also cause notorious symptoms of vertigo.
  • A number of conditions that involve the central nervous system may lead to vertigo including: migraine headaches, lateral medullary syndrome, multiple sclerosis
  • Vertigo is a sensation of spinning while stationary.
  • Repetitive spinning, as in familiar childhood games, can induce short-lived vertigo by disrupting the inertia of the fluid in the vestibular system

Vertigo is classified into either peripheral or central depending on the location of the dysfunction of the vestibular pathway

Peripheral:

Vertigo caused by problems with the inner ear or vestibular system is called “peripheral”, “otologic” or “vestibular”.

– The most common cause is benign paroxysmal positional vertigo (BPPV) but other causes include Meniere’s disease, superior canal dehiscence syndrome, labyrinthitis and visual vertigo.

– Any cause of inflammation such as common cold, influenza, and bacterial infections may cause transient vertigo if they involve the inner ear, as may chemical insults (e.g., aminoglycosides) or physical trauma (e.g., skull fractures).

– Motion sickness is sometimes classified as a cause of peripheral vertigo.

Central:

If vertigo arises from the balance centers of the brain, it is usually milder, and has accompanying neurologic deficits, such as slurred speech, double vision or pathologic nystagmus.

– Brain pathology can cause a sensation of disequilibrium which is an off-balance sensation.


Q. 21

Antiemetic Phenothiazine with labrynthine suppressant activityused for vertigo is ‑

 A

Prochlorperazine

 B

Cinnarazine

 C

Hyoscine

 D

Promethazine

Q. 21

Antiemetic Phenothiazine with labrynthine suppressant activityused for vertigo is ‑

 A

Prochlorperazine

 B

Cinnarazine

 C

Hyoscine

 D

Promethazine

Ans. A

Explanation:

Ans. is ‘A’ i.e., Prochlorperazine

Labyrinthine suppressants used in vertigo

They suppress end organ receptors or inhibit central cholinergic pathways in vestibular nuclei.

These are :‑

  1. Antihistaminics (with anticholinergic action) – cinnarizine, cyclizine, dimenhydrinate, diphenhydramine, promethazine.
  2. Anticholinergics- atropine, hyoscine.
  3. Antiemetic phenothiazines-prochlorperazine, thiethylperazine.

Q. 22

If a patient gets an attack of vertigo/dizziness by loud noise, he is having ‑

 A

Tullio phenomenon

 B

Dysplacusis

 C

Hyperacusis

 D

Paracusis

Q. 22

If a patient gets an attack of vertigo/dizziness by loud noise, he is having ‑

 A

Tullio phenomenon

 B

Dysplacusis

 C

Hyperacusis

 D

Paracusis

Ans. A

Explanation:

Ans. is ‘a’ i.e., Tullio phenomenon

Hyperacusis refers to sensation of discomfort or pain on exposure to normal sounds. It is seen in injury to nerve to stapedius and in case of congenital syphilis (Hennebert sign).

Displacusis is a condition where same tone is heard as notes of different pitch in either ear.

Paracusis willisii is a condition where patient hears a sound better in presence of background noise. It is seen in otosclerosis.

Tullio phenomenon is a condition where the subject gets attack of vertigo/dizziness by loud sounds.lt is seen in labyrinthine fistula and after fenestration surgery.



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