Brain Stem and Audio-Vestibular Regulation

  • Anupam MishraEmail author
  • Subhash Chandra Mishra
Original Article


The central pathologies present with perverted auditory perception and compromised postural control. Considering the existing controversy this study involves assessments of 100 cases of post fossa tumefactions in which a detailed clinical and neuro-otological (pure tone audiometry, electronystagmography, brainstem evoked response audiometry) profile is compared with their imaging patterns. The CP angle schwannomas (N = 26) presented with abnormal speech tests (N = 18), abnormal auditory adaptation (N = 7) and ABR with pathologically increased latency of wave V (N = 32), poor formation of wave I (N = 31) along with abnormal inter-wave interval (N = 32). In lesions (N = 32) compressing deeper nuclei, vermis and axial parts of brain stem, a gross truncal ataxia, incoordination, nystagmus, speech defects, subtotal deafness and bilateral ABR abnormalities were observed. The abnormal optomotor activities were seen as saccadic (N = 44) and deformed slow pursuit eye movements (N = 20). Inability to sustain holding function resulted in gaze nystagmus (N = 71), and poor timing manifested as fixation overshoots (N = 42). The midline cerebellar and upper brain stem lesions revealed bilateral OKN abnormalities whereas paramedian pathology showed only ipsilateral distortion. Caloric tests revealed culmination frequency as the most sensitive parameter for assessment of the hypo-reflexia in diffuse cerebellopathies while slow phase velocity in cases of posterior fossa lesion. The caloric hypo-activity appears to be of a better localizing value than the directional preponderance. The slow pursuit tracking revealed Type III curve perhaps due to defective regulation of slow movements in partially intact cerebellum (N = 15), while gross cerebellar dysfunctioning resulted into Type IV curve (N = 5).


Brainstem Cerebellum Audiovestibulopathy 



AM would like to acknowledge Professor. Dr. Girish Kumar Shukla and Professor Dr. Devika Nag for their time to time guidance.

Authors’ Contributions

AM in this Masters thesis project of his was the key person to recruit the patients from the departments of Neurology, Medicine and Otorhinolaryngology. He also conducted the basic anamnesis, otolaryngological examination, data entry and collection of references. The original idea of this work and design of study was framed by SCM who was the guide and supervisor of AM for his Masters thesis project of Otolaryngology. SCM was the final authority to decide the results of vestibular examination in situations of divided opinions if any. AM was also the main person to draft the manuscript (along with SCM) and obtaining inputs from the statistician. SCM was instrumental in assisting AM in vestibular assessment of the patients as well as providing important inputs for manuscript writing. Both the authors read and approved the final manuscript.

Conflict of interest

The authors declare that they have no competing interests.

Ethical Standard

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.


  1. 1.
    Calearo C, Antonelli A (1968) Audiometric findings in brain stem lesions. Acta Otolaryngol 66:305–319CrossRefGoogle Scholar
  2. 2.
    Carleton SC, Carpenter MB (1984) Distribution of primary vestibular fibers in the brainstem and cerebellum of the monkey. Brain Res 294:281CrossRefGoogle Scholar
  3. 3.
    Brodal A (1974) Anatomy of vestibular nuclei and their connections. In: Kornhuber HH (ed) Handbook of sensory physiology (the vestibular system, vol VI, part I). Springer, New YorkGoogle Scholar
  4. 4.
    Guyton AC, Hall JE (1996) The sense of hearing. In: Guyton AC, Hall JE (eds) Text book of medical physiology, 9th edn (Indian edition). Prism Books Pvt. Ltd., Bangalore, p 670Google Scholar
  5. 5.
    Gyton AC (1991) The cerebellum, the basal ganglion and overall motor control. In: Gyton AC (ed) Textbook of medical physiology, 8th edn. WB Saunders Co., Philadelphia, pp 617–626Google Scholar
  6. 6.
    Braitenberg V, Onesto N (1962) The cerebellar cortex as timing organ—discussion of a hypothesis. In: Proceedings of first congress of internal medicine, Cibernetica, Gianini, NaplesGoogle Scholar
  7. 7.
    Igarashi M, Ishikawa K (1985) Postlabyrinthectomy balance compensation with preplacement of cerebellar vermis lesion. Acta Otolaryngol 99(3–4):452–458CrossRefGoogle Scholar
  8. 8.
    Zimmerman RL (1994) Neurological disorders and examination. In: Katz Jack (ed) Hand book of clinical audiology, 4th edn. Williams and Wilkins, Baltimore, pp 25–36Google Scholar
  9. 9.
    Barin K (1987) Human postural sway responses to translational movements of the support surface. In: Proceedings of the IX conference of IEEE engineering in medicine and biology society, Boston, pp 745–747Google Scholar
  10. 10.
    Ferraro JA, Mincklar J (1977) The human lateral lemniscus and its nuclei. Brain Lang 4:277–294CrossRefGoogle Scholar
  11. 11.
    Keidel WD, Kallart S (1976) Auditory nerve system. In: Hinchcliffe R, Harrisson DFN (eds) Sceintific foundation of otolaryngology. William Heinemann Medical Books Ltd, London, pp 319–320Google Scholar
  12. 12.
    Snider RS, Stowell A (1944) Receiving areas of tactile, auditory and visual systems in cerebellum. J Neurophysiol 7:331–357CrossRefGoogle Scholar
  13. 13.
    Snider RS (1967) Functional alterations of cerebral sensory areas by cerebellum. Brain Res 25:322–333CrossRefGoogle Scholar
  14. 14.
    Hinchcliffe R (1976) Neuro-otology. In: Hinchcliffe R, Harrisson DFN (eds) Sceintific foundation of otolaryngology. William Heinemann Medical Books Ltd, London, pp 383–420Google Scholar
  15. 15.
    Kornhuber HH (1971) Motor functions of cerebellum and basal ganglia: the cerebellocortical saccadic (ballistic) clock, the cerebellonuclear hold regulator, and the basal ganglia ramp (voluntary speed smooth movements) generator. Kybernetik 8(4):157–162CrossRefGoogle Scholar
  16. 16.
    Ross AT, Zeman W (1967) Opsoclonus, occult carcinoma, and chemical pathology in dentate nuclei. Arch Neurol 17(5):546–551CrossRefGoogle Scholar
  17. 17.
    Musiek FE, Kibbe K (1986) Auditory brainstem responses: wave IV–V abnormalities in large cerebellopontine lesions. Am J Otol 7:253–257CrossRefGoogle Scholar
  18. 18.
    Ginsberg IA, White TP (1994) Otological disorders and examination. In: Katz Jack (ed) Hand book of clinical audiology, 4th edn. Williams and Wilkins, Baltimore, pp 6–24Google Scholar
  19. 19.
    Schwaber MK, Hall JW (1990) A simplified approach for transtympanic electrocochleography. Am J Otolaryngol 11:260–265Google Scholar
  20. 20.
    Musiek FE, Borenstein SP, Hall JW, Schwaber MK (1994) Auditory brainstem responses: neurodiagnosis and intraoperative applications. In: Katz Jack (ed) Hand book of clinical audiology, 4th edn. Williams and Wilkins, Baltimore, pp 351–374Google Scholar
  21. 21.
    Claussen CF (1970) Craniocorpography (CCG) in simple photo-optic registration method for vestibulospinal reactions. Z Laryngol Rhinol Otol (German) 49(10):634–639Google Scholar
  22. 22.
    Sekitani T, Honjo S, Mitani N, Shimamoto K (1976) Square drawing test. A new quantitative ataxia test. Agressologie 17(Spect D):35–40PubMedGoogle Scholar
  23. 23.
    Jongkees LBW, Mass JPM, Philipzoon AJ (1962) Clinical nystagmography. Practa Otolaryngol 24:65–93Google Scholar
  24. 24.
    Musick FE, Gollegly KM, Kibbe KS, Verkest SB (1988) Current concepts of the use of ABR and auditory psychophysical tests in the evaluation of brainstem lesions. Am J Otol 9(suppl):125–135Google Scholar
  25. 25.
    Mishra A, Shukla GK, Nag D, Mishra SC (2000) Hearing status in cerebellar disorders. Indian J Otol May(SAARC special volume):25–31Google Scholar
  26. 26.
    Cannon SC, Robinson DA (1987) Loss of neural integrator of the occulomotor system from the brainstem lesions in monkey. J Neurophysiol 57:1383–1409CrossRefGoogle Scholar
  27. 27.
    Leigh RJ, Zee DS (1982) The diagnostic value of abnormal eye movements, a pathophysiological approach. John Hopkins Med J 151(3):122–135Google Scholar
  28. 28.
    Fuchs AF, Luschi ES (1971) Development of isometric tension in simian extra-ocular muscle. J Physiol 219(1):55–66CrossRefGoogle Scholar
  29. 29.
    Uemura T, Cohen B (1973) Effects of vestibular nuclei lesions on vestibulo-ocular reflexes and posture in monkeys. Acta Otolaryngol (Suppl) 315:1–17Google Scholar
  30. 30.
    Norre ME (1987) Caloric vertical nystagmus. The vertical semicircular canal in caloric testing. J Otolaryngol 16:36–39PubMedGoogle Scholar
  31. 31.
    Krejcora H, Bojar M, Jerabek J (1988) Otoneurological symptomatology in Lyme disease. Adv Otolaryngol 42:210–212Google Scholar
  32. 32.
    Mc Donald TJ, Vollertsen RS, Young BR (1985) Cogan’s syndrome: audiovestibular involvement and prognosis in 18 patients. Laryngoscope 95:650–654Google Scholar
  33. 33.
    Steinmetz EF, Lebo CP, Norris FH Jr (1974) Electronystagmographic findings in motor neuron disease. Laryngoscope 84:281–289CrossRefGoogle Scholar
  34. 34.
    Waspe W, Cohen B, Raphen T (1985) Dynamic modification of vestibulo-ocular reflex by nodulus and uvula. Science 228:199–202CrossRefGoogle Scholar
  35. 35.
    Hain TC, Zee DS, Maria BL (1988) Tilt suppression of vestibulo-ocular reflex in patients with cerebellar lesions. Acta Otolaryngol (Stockh) 105:13–20CrossRefGoogle Scholar

Copyright information

© Association of Otolaryngologists of India 2019

Authors and Affiliations

  1. 1.Department of Otorhinolaryngology and Head and Neck SurgeryKing George′s. Medical UniversityLucknowIndia
  2. 2.Department of OtorhinolaryngologyNepalgunj Medical CollegeNepalgunjNepal

Personalised recommendations