Vertigo and facial nerve disorders

28 NEET-PG practice questions on Vertigo and facial nerve disorders, part of ENT. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

1. Question 1 · Medium

   A 67-year-old hypertensive man is brought to casualty with weakness of the left lower face. He can wrinkle his forehead and close both eyes normally, and his left arm is weak. What is the next best step?

   1. AElectroneurography of the facial nerve
   2. BOral prednisolone within 72 hours
   3. CMRI of the internal acoustic meatus
   4. DUrgent non-contrast CT brain

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   Answer: D · Urgent non-contrast CT brain

   Weakness of the lower face with the forehead spared is an upper motor neurone facial palsy, because the part of the facial nucleus supplying the upper face receives fibres from both cerebral hemispheres. With arm weakness in a hypertensive man, this is a likely stroke in the opposite (right) hemisphere. An urgent non-contrast CT separates haemorrhage from infarction so that thrombolysis can be considered within the time window. Treating it as Bell palsy would waste that time.

   • A: Electroneurography assesses peripheral nerve degeneration, not a central lesion.
   • B: Steroids are for Bell palsy, a lower motor neurone lesion involving the forehead.
   • C: Imaging of the internal acoustic meatus looks for a peripheral lesion, not a stroke.

2. Question 2 · Medium

   A 30-year-old woman has a complete right Bell palsy that began yesterday; she cannot close her right eye. The ENT resident counsels her with four statements: 1. Oral steroids started now improve her chance of full recovery. 2. Antiviral tablets alone would be as good as steroids. 3. She should use lubricating drops by day and tape the eye shut at night. 4. An MRI is needed before any treatment is started. Which statements are correct?

   1. A1, 3 and 4 only
   2. B1, 2 and 3 only
   3. C1 and 3 only
   4. D2 and 4 only

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   Answer: C · 1 and 3 only

   Statements 1 and 3 are correct. Steroids within 72 hours improve recovery in Bell palsy, and a cornea that cannot be closed must be protected from drying and exposure keratitis with artificial tears, ointment and taping at night. Statement 2 is wrong: antivirals alone have no proven benefit. Statement 4 is wrong: imaging is not needed in a typical case and must not delay treatment; it is done if the palsy is atypical, recurrent or does not begin to recover within a few months.

   • A: Includes routine MRI, which is not needed in a typical case.
   • B: Includes antiviral monotherapy, which is not effective.
   • D: Omits steroids and eye care, the two essential steps.

3. Question 3 · Medium

   A 44-year-old woman has had four episodes over six months of spinning vertigo lasting 2-4 hours, with vomiting, roaring tinnitus and fullness in her left ear. Between attacks her hearing is reduced but varies. Audiometry shows a left sensorineural loss mainly at low frequencies. What is the underlying pathology?

   1. AEndolymphatic hydrops
   2. BFixation of the stapes footplate
   3. CInflammation of the vestibular nerve
   4. DOtoconia in the posterior canal

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   Answer: A · Endolymphatic hydrops

   Episodic vertigo lasting hours, fluctuating low-frequency sensorineural loss, tinnitus and aural fullness make up Meniere disease. The pathology is endolymphatic hydrops: too much endolymph, from excess production or poor absorption by the endolymphatic sac, distends the cochlear duct and saccule. Ruptures and leaks of the membranes are thought to cause the attacks. Over years the hearing loss may become permanent and flat.

   • B: Stapes fixation causes conductive loss without vertigo.
   • C: Vestibular neuritis causes one long attack of vertigo without hearing loss.
   • D: Canal otoconia cause BPPV with brief positional vertigo and normal hearing.

4. Question 4 · Hard

   A 69-year-old diabetic, hypertensive man has had continuous vertigo with vomiting for 6 hours. Hearing is normal. The head impulse test is normal on both sides, the nystagmus beats to the right on right gaze and to the left on left gaze, and the cover test shows a vertical skew deviation. He cannot stand without falling. What is the next best step?

   1. AEpley repositioning manoeuvre
   2. BReassurance and vestibular sedatives
   3. CMRI brain with diffusion-weighted images
   4. DOral steroids for vestibular neuritis

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   Answer: C · MRI brain with diffusion-weighted images

   In acute continuous vertigo, a normal head impulse test, direction-changing nystagmus and skew deviation (a 'dangerous' HINTS result) point to a central cause, most often a posterior circulation stroke of the cerebellum or brainstem. Inability to stand also favours a central lesion. MRI with diffusion-weighted imaging is the investigation of choice; CT often misses posterior fossa infarcts, and even early MRI can be falsely negative. Treating him as vestibular neuritis could miss a cerebellar infarct, which can swell and compress the brainstem.

   • A: Epley treats positional BPPV, not continuous vertigo with central signs.
   • B: Sedatives and reassurance would miss a stroke.
   • D: Neuritis gives an abnormal head impulse and unidirectional nystagmus.

5. Question 5 · Medium

   A 24-year-old man in a road traffic accident has blood from the right ear and a CT showing a longitudinal fracture of the right temporal bone. His face moved normally on admission, but on day 3 a right lower motor neurone facial palsy appears. What is the most appropriate management?

   1. AHypoglossal-facial anastomosis
   2. BCorticosteroids and observation
   3. CImmediate surgical decompression
   4. DFacial nerve grafting in a week

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   Answer: B · Corticosteroids and observation

   Facial palsy that appears days after a temporal bone fracture is caused by swelling of a nerve that is still in continuity, and most such patients recover well with conservative treatment, including steroids and eye care. An immediate, complete palsy suggests the nerve is cut or compressed by a bone fragment, which may need exploration. Longitudinal fractures are the commoner type and usually give conductive hearing loss, while transverse fractures more often damage the facial nerve and the inner ear. Serial testing of the nerve guides management.

   • A: Nerve crossover is a late reanimation step when the facial nerve cannot recover.
   • C: Immediate decompression is considered for a complete palsy present from the moment of injury.
   • D: Grafting is for a nerve proven to be divided, not for delayed swelling.

6. Question 6 · Easy

   A 32-year-old software engineer from Bengaluru woke up with drooling from the right corner of his mouth. He cannot close his right eye or wrinkle the right side of his forehead. There is no rash, ear discharge or other neurological deficit. It began 24 hours ago. What is the most appropriate drug treatment?

   1. AOral acyclovir alone for 7 days
   2. BIV methylprednisolone pulse
   3. COral pregabalin for 2 weeks
   4. DOral prednisolone for 10 days

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7. Question 7 · Medium

   A 28-year-old woman has a right lower motor neurone facial palsy that began two days ago. Taste is lost over the right anterior two-thirds of the tongue, loud sounds are uncomfortable in the right ear, and the Schirmer test shows reduced tear production on the right. At which level is the facial nerve lesion?

   1. AAt the stylomastoid foramen
   2. BBelow the chorda tympani in the canal
   3. CAt or above the geniculate ganglion
   4. DBetween the nerve to stapedius and chorda tympani

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8. Question 8 · Easy

   A 58-year-old woman has brief spells of spinning vertigo, each lasting under a minute, when she turns over in bed or looks up to a high shelf. Hearing is normal. When she is lowered with her head turned to the right and hanging below the couch, a torsional, upbeating nystagmus begins after a few seconds and fades within 30 seconds. What is the treatment of choice?

   1. AEpley canalith repositioning
   2. BOral prednisolone for a week
   3. CLong-term betahistine
   4. DIntratympanic gentamicin

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9. Question 9 · Medium

   A 35-year-old man developed severe continuous vertigo with nausea two days ago, a week after a viral fever. He cannot walk without support. Hearing is normal and there is no tinnitus. He has a horizontal nystagmus beating to the right in all directions of gaze, and a head impulse test to the left shows a corrective saccade. What is the most likely diagnosis?

   1. ALeft Meniere disease
   2. BLeft posterior canal BPPV
   3. CLeft vestibular neuritis
   4. DRight vestibular neuritis

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10. Question 10 · Medium

    A 55-year-old diabetic man has severe pain in his left ear for three days, followed by left facial weakness involving the forehead. There are small vesicles on the concha and in the ear canal, and he has some hearing loss and vertigo. What is the most appropriate treatment?

    1. AUrgent facial nerve decompression
    2. BTopical antibiotic ear drops
    3. COral prednisolone alone
    4. DValacyclovir with oral prednisolone

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11. Question 11 · Medium

    A 47-year-old shopkeeper is diagnosed with left Meniere disease after recurrent attacks of vertigo with fluctuating hearing loss. This is his first visit, and between attacks he has mild disability. What is the most appropriate initial management?

    1. AEpley repositioning manoeuvre
    2. BSalt restriction and betahistine
    3. CIntratympanic gentamicin
    4. DSurgical labyrinthectomy

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12. Question 12 · Medium

    A 39-year-old woman with recurrent episodes of vertigo and fluctuating left-sided deafness is seen in the ENT OPD. The resident lists four statements about her likely condition: 1. The basic lesion is distension of the endolymphatic system. 2. Early in the disease the hearing loss is mainly at low frequencies. 3. Rinne test will be negative on the affected side. 4. The Epley manoeuvre is the definitive treatment. Which statements are correct?

    1. A2 and 3 only
    2. B1, 2 and 3 only
    3. C1, 2 and 4 only
    4. D1 and 2 only

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13. Question 13 · Medium

    A 62-year-old woman has brief vertigo on lying down and rolling over in bed, starting a week after a minor fall in which she hit her head. A Dix-Hallpike test confirms posterior canal involvement. Where do the particles causing her symptoms come from?

    1. AOtoconia dislodged from the utricle
    2. BCrystals formed in the cochlear duct
    3. CDebris from the endolymphatic sac
    4. DCalcium shed by the saccule into perilymph

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14. Question 14 · Hard

    A 50-year-old man has brief vertigo whenever he lies down. In the Dix-Hallpike test with the head turned to the left, after a latency of 4 seconds an upbeating nystagmus appears with the upper poles of the eyes beating towards the left (lower) ear, lasting 20 seconds and less marked on repetition. The test to the right is negative. What is the diagnosis and treatment?

    1. ALeft posterior canal BPPV; left Epley manoeuvre
    2. BRight posterior canal BPPV; right Epley manoeuvre
    3. CLeft horizontal canal BPPV; barbecue roll
    4. DCentral positional vertigo; MRI brain

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15. Question 15 · Medium

    Consider these statements about Bell palsy: 1. An incomplete palsy at presentation predicts a good recovery. 2. Electroneurography showing more than 90% degeneration within the first 2 weeks predicts a poor recovery. 3. Oral steroids help most when started within 72 hours. 4. Most patients need surgery to recover full function. Which statements are correct?

    1. A2, 3 and 4 only
    2. B1, 2 and 3 only
    3. C1 and 4 only
    4. D3 and 4 only

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16. Question 16 · Medium

    Bell palsy on the right was diagnosed this morning in an auto-rickshaw driver who has had a complete right lower motor neuron facial palsy for 24 hours. Oral prednisolone has been started. He cannot close his right eye; Bell's phenomenon is visible, and the cornea is clear. He rides in dust all day. What else is most important now?

    1. AEye protection with lubricants and night taping
    2. BImmediate surgical facial nerve decompression
    3. CMRI of the brain before steroids are continued
    4. DPhysiotherapy with electrical stimulation of the face

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17. Question 17 · Easy

    Episodes of vertigo lasting 2-3 hours, roaring tinnitus and fullness in the left ear trouble a shopkeeper in Kozhikode every few weeks. Between attacks his hearing seems to come back. Audiometry done during a bad week shows a left sensorineural loss. Which audiometric pattern is typical of this disease in its early stage?

    1. ALow-frequency loss that fluctuates
    2. BHigh-frequency loss with a notch at 4 kHz
    3. CHigh-frequency loss sloping down to 8 kHz
    4. DFlat conductive loss with an air-bone gap

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18. Question 18 · Easy

    Which bedside test confirms posterior semicircular canal BPPV?

    1. AHead impulse test
    2. BFukuda stepping test
    3. CRomberg test
    4. DDix-Hallpike test

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19. Question 19 · Hard

    After a road traffic accident, a motorcyclist is conscious and stable in the casualty of a trauma centre. Blood and clear fluid trickle from his right ear. Nurses noted at arrival that his whole right face was paralysed, and it remains completely paralysed 2 days later. HRCT shows a temporal bone fracture line crossing the otic capsule, with a bony spicule in the region of the facial nerve near the geniculate ganglion. Schirmer test shows reduced tearing on the right. Electroneurography on day 4 shows 95% degeneration. What is the most appropriate management?

    1. AHypoglossal-facial anastomosis now
    2. BPhysiotherapy and eye care alone
    3. CHigh-dose steroids and observe for 6 months
    4. DSurgical exploration and decompression of the facial nerve

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20. Question 20 · Medium

    Months after recovery from a right Bell palsy, a woman notices that her right eye waters every time she eats, especially spicy food. Her facial movements have returned except for some twitching of the eye when she smiles. What is the mechanism of the watering?

    1. AIrritation of the trigeminal nerve during chewing
    2. BExposure keratitis from incomplete eye closure
    3. CRegenerating salivary fibres reaching the lacrimal gland
    4. DBlockage of the right nasolacrimal duct

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21. Question 21 · Medium

    For the third time in five years, a schoolgirl from Ernakulam has a left lower motor neuron facial palsy, each time recovering. Her upper lip has been swollen on and off, and her tongue shows deep furrows. What is the most likely diagnosis?

    1. AHeerfordt syndrome
    2. BRamsay Hunt syndrome
    3. CMelkersson-Rosenthal syndrome
    4. DRecurrent Bell palsy

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22. Question 22 · Hard

    Over two years, in spite of salt restriction, betahistine, diuretics and two courses of intratympanic steroid, a farmer from Wayanad with definite left Meniere disease has had disabling vertigo attacks several times a month. He has fallen in the field twice. The left ear now has a flat 75 dB sensorineural loss with 20% discrimination, and the right ear is normal. MRI of the internal auditory canals is normal, and he has no migraine. He wants the attacks stopped and accepts any further hearing loss in the left ear. What is the most appropriate next treatment?

    1. AEndolymphatic sac decompression
    2. BIntratympanic gentamicin to the left ear
    3. CLifelong vestibular sedatives
    4. DCochlear implant in the left ear

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23. Question 23 · Medium

    In suspected Meniere disease, which test showing a raised summating potential to action potential (SP/AP) ratio supports the diagnosis of endolymphatic hydrops?

    1. AOtoacoustic emissions
    2. BElectrocochleography
    3. CVideonystagmography
    4. DBrainstem evoked response audiometry

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24. Question 24 · Medium

    Each time she rolls over in bed onto either side, a retired nurse has intense vertigo lasting about 40 seconds. Dix-Hallpike is negative on both sides. In the supine roll test, turning the head to either side produces horizontal nystagmus beating towards the lower ear, stronger on turning to the right. She has had no recent viral illness. Hearing is normal, there are no neurological signs, and the head impulse test is normal on both sides. She takes medicine for hypertension. Which manoeuvre should be used to treat her?

    1. AEpley manoeuvre for the right ear
    2. BBrandt-Daroff exercises only
    3. CSemont liberatory manoeuvre
    4. DBarbecue (Lempert) roll towards the left

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25. Question 25 · Hard

    A man with diabetes and hypertension develops sudden continuous vertigo with vomiting and cannot walk unaided. There is no hearing loss. The findings of the bedside head impulse, nystagmus and test of skew are charted. What is the correct next step?

    

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    1. AVestibular suppressants and discharge with outpatient review
    2. BIntratympanic steroid injection
    3. CEpley manoeuvre at the bedside
    4. DUrgent MRI of the brain with diffusion-weighted images

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