Actual Exam 1

Question 1

Which of the following regarding epidemiology and population demographics of dizziness / balance disorders is FALSE?
Dizziness is one of the most common complaints in outpatient clinics
Dizziness is the #1 complaint to medical providers for individuals over 70 years of age
The number of older individuals (those over 65 years of age) is expected to decrease by 2030 driving healthcare costs down
Falls are one of the leading causes of brain injury (TBI) and fractures
50% of individuals over age 70 will experience BPPV at some point

Answer 1

The number of older individuals (those over 65 years of age) is expected to decrease by 2030 driving healthcare costs down

Question 3

Which of the following statements are TRUE? Select ALL that apply.
Dizziness is a general term which may include descriptions such as lightheadedness, floating, pre-syncope, or loss of equilibrium but without sensation of rotation
Vertigo is a term used to describe sense of rotational movement either of onself (subjective) or one’s surroundings (objective)
Vertigo is more likely to be of central (or non-vestibular) origin whereas “dizziness” is more likely to be of peripheral origin
Many individuals do not fully understand the distinction between dizziness and vertigo therefore it is important to question them about their specific complaint when taking your case history
Imbalance is always peripheral in origin and not likely to be related to central conditions or other factors

Answer 3

Dizziness is a general term which may include descriptions such as lightheadedness, floating, pre-syncope, or loss of equilibrium but without sensation of rotation
Vertigo is a term used to describe sense of rotational movement either of onself (subjective) or one’s surroundings (objective)
Many individuals do not fully understand the distinction between dizziness and vertigo therefore it is important to question them about their specific complaint when taking your case history

Question 4

Balance depends upon sensory information gathered from what 3 systems?

Answer 4

vestibular, visual, and somatosensory

Question 5

When discussing vestibular anatomy, “peripheral” refers to which of the following?

Answer 5

Labyrinth & 8th nerve up to the point it enters the brainstem

Question 6

When discussing vestibular anatomy, “central” refers to which of the following?
Semicircular canals and otolithic organs
Cerebellum only
Brainstem to cortex
Labyrinth & VIIIth nerve up to the point it enters the brainstem
VIIIth nerve and brainstem

Answer 6

Brainstem to cortex

Question 7

“Vision denied” refers to eyes closed (ENG) or eyes covered (VNG) or the scenario where the patient is without a visible target?

Answer 7

true

Question 8

What are the two sensory structures within the peripheral vestibluar system and what type of stimuli does each respond to? Be brief but specific.
The first sensory structure is the cristae ampullaris in

Answer 8

The two sensory structures in the peripheral vestibular system are the crista ampullaris and the maculae. The crista ampularis is responsive to angular (rotational) movement and the maculae is responsive to linear (translational) movement and to gravity.

Question 9

The semicircular canals are located within the membranous labyrinth, contain periplymph and are surrounded on the outside by endolymph and the bony labyrinth?

Answer 9

false

Question 10

Which the following are TRUE regarding the semicircular canals? Select ALL that apply.
The semicircular canals function in a complimentary or push-pull relationship with the opposite ear
The semicircular canals detect motion in the pitch, yaw and roll planes
The semicircular canals are arranged orthogonal or roughly right angles to each other
The semicircular canals are connected to each other but have no connection with the otolithic organs or rest of the vestibule
The semicircular canals have an enlarged area on both ends called the ampulla and are closed off on one end with no fluid connection to the vestibule

Answer 10

The semicircular canals function in a complimentary or push-pull relationship with the opposite ear
The semicircular canals detect motion in the pitch, yaw and roll planes
The semicircular canals are arranged orthogonal or roughly right angles to each other

Question 12

Which of the following are TRUE regarding the otolithic organs? Select ALL that apply.
The otolithic organs are arranged perpindicular to each other
The saccule has calcium carbonate particles called otoconia embedded on top but the utricle does not
The utricle is larger and oriented above the saccule which is smaller and oriented below
Unlike the SCCs, the otolithic organs do not possess any vestibular hair cells
Displaced otoconia from the utricular macula is what causes BPPV

Answer 12

The otolithic organs are arranged perpindicular to each other
The utricle is larger and oriented above the saccule which is smaller and oriented below
Displaced otoconia from the utricular macula is what causes BPPV

Question 13

The semicircular canals work as complimentary pairs during head/body rotation. Match the semicircular canal on the left with its complimentary pair on the right during stimulation.
Left anterior SCC -
Left horizontal SCC -
Left posterior SCC -

Answer 13

Right posterior SCC
Right horizontal SCC
Right anterior SCC

Question 14

Which of the following statements is FALSE?
The cupula of the SCCs has roughly the same density of the surrounding endolymph and is therefore not sensitive to gravity
Movement of hair cell stereocilia toward the kinocilium results in depolarization and an increase in neural activity
Movement of hair cell stereocilia away the kinocilium results in hyperpolarization and a decrease in neural activity
Movement of hair cell stereocilia toward the kinocilium results in hyperpolarization and an increase in neural activity
There are two types of vestibular hair cells; type I and type II but their exact functional differences aren’t clearly understood

Answer 14

Movement of hair cell stereocilia toward the kinocilium results in hyperpolarization and an increase in neural activity

Movement of hair cell stereocilia toward the kinocilium results in depolarization and an increase in neural activity

Question 15

For the horizontal SCCs, endolymph movement toward the ampulla (i.e., ampullopetal) results in an __________ response, whereas endolymph movement away from the ampulla (i.e., ampullofugal) results in an __________ response.
inhibitory, excitatory
excitatory, excitatory
inhibitory, inhibitory
excitatory, inhibitory
neutral, excitatory

Answer 15

excitatory, inhibitory

Question 16

For the anterior and posterior SCCs, endolymph movement toward the ampulla (i.e., ampullopetal) results in an __________ response, whereas endolymph movement away from the ampulla (i.e., ampullofugal) results in an __________ response.
excitatory, inhibitory
inhibitory, excitatory
excitatory, excitatory
inhibitory, inhibitory
neutral, excitatory

Answer 16

inhibitory, excitatory

Question 17

What are the 3 vestibular reflexes we discussed and give a brief description of the purpose of each.

Answer 17

Vestibulo-ocular reflex (VOR) – generates reflexive eye movement to enable clear vision during head movement

Vestibulocollic reflex (VCR) – acts on the neck musculature to stabilize the head helping to keep the head in horizontal gaze position relative to gravity (accomplished w/ neck musculature rather than eye musculature)

Vestibulospinal reflex (VSR) – generates compensatory body movements to maintain head and postural stability in upper and lower limbs

Question 18

If an individual was reporting oscillopsia, which vestibular reflex would you expect to be impaired?

Answer 18

vor

Question 19

What are the 3 cranial nerves involved in eye movement?
Oculomotor (III), Trigeminal (V) and Hypoglossal (XII)
Oculomotor (III), Trochlear (IV) and Abducens (VI)
Oculomotor (III), Vestibulo-cochlear (VIII) and Vagus (X)
Oculomotor (III), Trigeminal (V) and Facial (VII)
Optic (II), Oculomotor (III) and Vagus (X)

Answer 19

Oculomotor (III), Trochlear (IV) and Abducens (VI)

Question 20

When analyzing nystagmus, we “describe” nystagmus based upon the direction of the fast phase (central component) but “measure” the magnitude of the nystagmus based upon the slow phase (peripheral component)?

Answer 20

true

Question 21

Which of the following statements is TRUE regarding nystagmus?
Nystagmus beats toward a stimulated ear and away from an inhibited ear
Nystagmus beats toward an inhibited ear and away from an stimulated ear
Nystagmus is independent of stimulation
Rightward (yaw) rotations generate leftward nystagmus
Nystagmus direction is solely dependent upon the neural integrator

Answer 21

Nystagmus beats toward a stimulated ear and away from an inhibited ear

Question 22

When examining ENG/VNG tracings, which of the following are TRUE?
For horizontal recordings, upward deflections represent rightward eye movements and downward represent leftward eye movements
For horizontal recordings, upward deflections represent lefward eye movements and downward represent rightward eye movements

Answer 22

For horizontal recordings, upward deflections represent rightward eye movements and downward represent leftward eye movements

Question 23

For paretic lesions, which of the following are TRUE regarding nystagmus?
Nystagmus direction typically has nothing to do with side of lesion
Nystagmus typically beats toward the affected ear
Nystagmus typically beats away from the affected ear

Answer 23

Nystagmus typically beats away from the affected ear

Question 24

For irritative lesions (like Meniere’s disease), when active, which of the following are TRUE regarding nystagmus?
Nystagmus typically beats toward the affected ear
Nystagmus typically beats away from the affected ear
Nystagmus direction typically has nothing to do with side of lesion

Answer 24

Nystagmus typically beats toward the affected ear

Question 25

Poorly compensated or decompensated vestibular lesions may sometimes have nystagmus patterns that do not obey the conventional directions?

Answer 25

true

Question 26

Which of the following regarding vestibular anatomy is FALSE? There are 2 types of vestibular hair cells; type I (spherical shape) and type II (cylinderical shape) but further differences are not well understood Otolithic hair cells are arranged in button-like sheets Hair cells are arranged away from the striola in the utricle and toward the striola in the saccule Hair cells are arranged toward the striola in the utricle and away from the striola in the saccule Vestibular hair cells have one tall stereocilia called the kinocilium

Answer 26

Hair cells are arranged away from the striola in the utricle and toward the striola in the saccule Hair cells are arranged toward the striola in the utricle and away from the striola in the saccule

Question 27

Match the vestibular structure on the left with the innervating nerve branch on the right. Anterior Semicircular Canal - Horizontal Semicircular Canal - Posterior Semicircular Canal - Utricle - Saccule -

Answer 27

Superior vestibular nerve branch Superior vestibular nerve branch Inferior vestibular nerve branch Superior vestibular nerve Inferior vestibular nerve branch

Question 28

Which of the following are TRUE regarding ENG/VNG testing? Select ALL that apply. When analyzing oculomotor normative data you should also visually inspect oculography morphology to confirm abnormal data points actually look abnormal Poor vision, certain medications and patient arousal / fatigue can affect oculomotor findings Abnormalities encountered during the oculomotor exam are more likely to be peripheral findings than central findings Oculomotor abnormalities should be repeatable for them to be considered truly abnormal If you have 1 or 2 data points in the "abnormal" range, it is still considered an abnormal oculomotor exam

Answer 28

When analyzing oculomotor normative data you should also visually inspect oculography morphology to confirm abnormal data points actually look abnormal Poor vision, certain medications and patient arousal / fatigue can affect oculomotor findings Oculomotor abnormalities should be repeatable for them to be considered truly abnormal

Question 29

Which of the following types of eye movements do we NOT test during ENG/VNG testing? Saccades Smooth pursuits Gaze Holding Optokinetic (OPK/OKN) Vergence

Answer 29

Vergence

Question 30

A patient arrives at your clinic for acute vertigo. Upon examination you note a right-beating nystagmus in center gaze (spontaneous) which increases in magnitude when they gaze to their right and decreases in magnitude when they gaze to their left. What is the phenomena or finding they are demonstrating? Is this a central sign, a peripheral sign or a non-localizing finding?

Answer 30

Alexander's Law peripheral sign

Question 31

When an individual has a pre-existing nystagmus and gazes in the direction of the fast phase of the nystagmus, the magnitude increases. Gazing away from the fast phase causes it to reduce in magnitude. This is a peripheral sign. It is the ONLY exception to your oculomotor battery which otherwise denotes central findings only.

Answer 31

alexanders

Question 32

What are the 3 parameters we evaluate when performing saccade testing and what does each measure?

Answer 32

Velocity = speed of eye movement Accuracy = ability to correctly acquire the target without over or undershooting Latency = time it takes to acquire the target post-stimulus movement

Question 33

speed of eye movement

Answer 33

velocity

Question 34

ability to correctly acquire the target without over or undershooting

Answer 34

accuracy

Question 35

time it takes to acquire the target post-stimulus movement

Answer 35

latency

Question 36

What are the two parameters we evaluate when performing pursuit testing and what does each measure?

Answer 36

Gain = eye movement relative to target Symmetry(phase) = rightward vs leftward comparison

Question 37

eye movement relative to target

Answer 37

gain

Question 38

rightward vs leftward comparison

Answer 38

symmetry (phase)

Question 39

What is the weakest subtest in your oculomotor exam?

Answer 39

OPK/OKN

Question 40

What is BPPV? How does it occur? Briefly describe the two variants.

Answer 40

Benign Paroxysmal positional vertigo. Otoconia become dislodged from the utricle and end up in the semicircular canals. Movement of the head causes the otoconia in the canal to move and stimulates the vestibular system causing false sense of vertigo. "Canalithiasis" or otoconia freely moving in the endolymph and "Cupulolithiasis" or otoconia in contact with the cupula are the 2 types.

Question 41

Which maneuver is used to EVALUATE FOR anterior and posterior canal BPPV? Dix-Hallpike maneuver Pagnini-McClure maneuver Valsalva maneuver The BBQ roll The Trendelenburg maneuver

Answer 41

Dix-Hallpike maneuver

Question 42

Which maneuver is used to EVALUATE FOR horizontal canal BPPV? The Dix-Hallpike maneuver The Supine Head Roll (Pagnini-McClure) maneuver The Epley maneuver The Hook maneuver The Semont maneuver

Answer 42

The Supine Head Roll (Pagnini-McClure) maneuver

Question 43

What is the most common type of BPPV (variant and which canal) with up to 90-95% of recorded cases?

Answer 43

Posterior canal canalithiasis BPPV

Question 44

Which of the following maneuvers, that we discussed in class, are used to TREAT anterior/posterior canalithiasis BPPV. Select 2 answers. The Epley (canalith repositioning) maneuver The Semont (Liberatory) maneuver The BBQ roll (Lempert maneuver) The Valsalva maneuver The Toynbee maneuver

Answer 44

he Epley (canalith repositioning) maneuver The Semont (Liberatory) maneuver

Question 45

Which of the following maneuvers, that we discussed in class, are used to TREAT horizontal canal canalithiasis BPPV. The Epley (canalith repositioning) maneuver The Semont (Liberatory) maneuver The BBQ roll (Lempert maneuver) The Dix-Hallpike maneuver The Toynbee maneuver

Answer 45

The BBQ roll (Lempert maneuver)

Question 46

Eye recording technique that uses changes in the corneo-retinal potential and surface electrodes to track eye movement

Answer 46

EOG/ENG

Question 47

Eye recording technique that uses pupil localization technology, mirrors and infrared diodes to track eye movements

Answer 47

VOG/VNG

Question 48

Eye recording technique that uses a metallic loop embedded in the eye or in a tight fitting contact to detect changes in electromagnetic fields and detect eye position

Answer 48

Scleral search coils

Question 49

Eye recording technique that requires extra time for the eyes to "adapt" to light and darkened environments when goggles open/closed

Question 50

Eye recording technique that has higher resolution and allows for video playback

Answer 50

VOG/VNG

Question 51

Vestibular tests are tests of function and can therefore be affected by medications, arousal state and patient effort?

Answer 51

true

Question 52

List 3 things or questions you would ask a patient who complained of dizziness prior to performing a vestibular evaluation? We discussed several in class. Be brief but specific.

Answer 52

Description = What are you experiencing Timing = How long does it last when present or is it continuous Frequency = How often does it occur Provoking Factors = What causes it Associated Symptoms Any Other Medical Hx Medications

Question 53

When performing static positional testing, if an individual demonstrates nystagmus what additional actions should you take? Ask the patient if they are experiencing any subjective dizziness/vertigo Perform body (lateral) right and left as well to rule out torsion of the neck as contribution to nystagmus Utilize a visual target for part of the recording to determine if the nystagmus changes in intensity with visual fixation Wait at least 30 seconds or more to see if the nystagmus fatigues with time or changes direction All of these choices are correct

Answer 53

all

Question 54

In the absence of any other abnormality (i.e., normal oculomotor and normal caloric exams), nystagmus observed during static positional testing is considered?

Answer 54

peripheral finding

Question 55

In order for static positional nystagmus to be considered "abnormal" it has to meet specific criteria. Which of the following is NOT one of those criterion? Nystagmus is present in ALL positions Nystagmus changes direction in any single head position or positions Nystagmus is vertical regardless of intensity Nystagmus is persistent in at least 3 head positions Nystagmus magnitude is equal to or greater than 4 deg/sec (VNG), 6 deg/sec (ENG) in any head position

Answer 55

Nystagmus is vertical regardless of intensity

Question 56

Which of the following is NOT a common feature of posterior canalithiasis BPPV? Escalation (constant repetition of the offending maneuver will cause the nystagmus to increase on subsequent trials) Delayed onset latency (nystagmus and vertigo begin after a short interval upon putting patient in offending position) Duration (nystagmus and vertigo eliminate in 1 minute or less) Linear rotary direction (nystagmus is up-beating or down-beating torsional) Reversal (nystagmus may show a milder and reversed direction upon bringing the patient back up post maneuver)

Answer 56

Escalation (constant repetition of the offending maneuver will cause the nystagmus to increase on subsequent trials)

Question 57

Patient tasking or alerting should be performed during static positional testing?

Answer 57

true

Question 58

What is the most common bedside exam used to screen VOR function and briefly describe how it is performed. (We did it in lab and watched videos). What would a normal result versus an abnormal result look like?

Answer 58

Halmagyi head thrust or head impulse test. Clinician grasps patient by the head and uses rapid unexpected head turns to examine the VOR Patient is asked to keep his/her eyes focused on a target (e.g., clinician’s nose or forehead) Head should be thrust in the direction of or plane of semicircular canals Head movement should not exceed 20-30 degrees in any direction but must be high acceleration (>3000 deg/sec/sec) Head should be held briefly at the end of impulse to monitor for re-fixation saccades Normal individual will exhibit no corrective / re-fixation saccades and the Impaired individual will exhibit re-fixation saccades in direction of lesion

Question 59

Name one bedside test that can be used to screen VSR function for postural stability.

Answer 59

fukuda/unterberger

Question 60

For the phenomena (nystagmus) shown in alexanders, what is the most likely site of lesion?

Answer 60

peripheral finding

Question 61

Name two types of "normal" physiologic nystagmus.

Answer 61

Endpoint (sustained or unsustained) Fatigue nystagmus Optokinetic nystagmus

Question 62

What was the name of either of the mechanical BPPV treatment devices (pictured below) that we discussed in our BPPV lecture and were featured in the supplementary BPPV videos in your Canvas Readings/Resources (if you viewed them)? The first one received FDA clearance for sale in the United States in 2022. The other device has been around for several years and was endorsed by a prominent otologist.

Answer 62

Omniax - Gyroscopic chir