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Ear Pathology Quiz

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A 42-year-old woman has brief episodes of vertigo (a spinning sensation) lasting seconds when she rolls over in bed or looks up suddenly. She has no hearing loss or tinnitus (ringing in the ear). Which underlying mechanism best explains her symptoms?

A Impaired otolith function in the utricle causing reduced detection of head tilt and linear acceleration
B Increased endolymph volume in the cochlea and vestibular labyrinth causing episodic vertigo
C Inflammation of the vestibular nerve causing abnormal signalling in the vestibular pathway
D Displaced crystals in a semicircular canal causing abnormal movement of endolymph ✓
E Leakage of perilymph from the oval window causing vertigo that follows changes in middle-ear pressure

The answer is D: Displaced crystals in a semicircular canal causing abnormal movement of endolymph

Explanation

Why D is correct

See Conditions of the Inner Ear. Option D is correct: this is benign paroxysmal positional vertigo (BPPV), which is caused by crystals forming in the semicircular canals of the inner ear that continue to move after the head becomes stationary, causing vertigo that settles. Paroxysmal means coming in sudden short attacks, positional means that certain head positions trigger them, and benign means it is not dangerous. BPPV is the most common cause of vertigo seen in clinical practice, and it is typically brought on by specific movements, such as turning over in bed, looking upwards or bending over. Because the hearing part of the ear (the cochlea) is not involved, it causes no hearing abnormality. It is diagnosed with the Dix-Hallpike manoeuvre, a bedside test that demonstrates the characteristic findings, and it is treated with a particle repositioning manoeuvre such as the Epley manoeuvre. It often settles by itself, although recurrence is common. A simple memory aid: brief spins with head movement and normal hearing means BPPV.

Cause: Crystals in the semicircular canals keep moving after the head becomes still.
Pattern: Brief vertigo triggered by head position, with normal hearing.
Test and treatment: The Dix-Hallpike manoeuvre confirms it and the Epley manoeuvre treats it.

Why the other options are incorrect

A. Impaired otolith function in the utricle causing reduced detection of head tilt and linear acceleration: The utricle detects head tilt and linear acceleration, so damage to it tends to cause persistent imbalance or gait problems rather than brief rotatory vertigo on turning over. This option affects the wrong balance organ.
B. Increased endolymph volume in the cochlea and vestibular labyrinth causing episodic vertigo: Increased endolymph volume is the proposed basis of Ménière's disease, whose attacks usually last minutes to hours and are accompanied by hearing loss and tinnitus. This woman has no hearing symptoms and her episodes last only seconds.
C. Inflammation of the vestibular nerve causing abnormal signalling in the vestibular pathway: Inflammation of the vestibular nerve causes vestibular neuritis, which typically produces a single more prolonged episode of continuous vertigo with nausea, not recurrent seconds-long attacks triggered by head position. The brief positional pattern is the key clue against this option.
E. Leakage of perilymph from the oval window causing vertigo that follows changes in middle-ear pressure: A perilymph leak can cause vertigo with pressure changes, coughing or straining, but it does not classically present as brief positional episodes when rolling over or looking up. The pattern would not be this short-lived with normal hearing.

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More questions from this set. Start the quiz to answer them and see each explanation.

1
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2
A 7-year-old child is brought to the GP with fever and ear pain, after a recent episode of acute otitis media that has not improved despite oral antibiotics. There is redness, tenderness and swelling over the area behind the ear, and the pinna is pushed forwards. Which underlying pathological process best explains these findings?

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