ANATOMY AND

PHYSIOLOGY OF
VESTIBULAR ORGAN
AND NEURAL PATHWAYS

Dr. Vineet Chadha

Resident
Deptt of ENT and Head & Neck
Surgery
SMS Medical College, Jaipur
 Introduction
• Vestibular system is the organ of balance and equillibrium.
• It is embedded within the petrous part of temporal bone.
• Function
• Detection of body motion
• Detection of head in space in relation to gravity
 Vestibule
• The central chamber of
the bony labyrinth and
measures 4 mm in
diameter.
• It is situated between
the internal auditory
meatus anteromedially
and middle ear cavity
laterally
q Lateral wall – oval
window
q Medial wall – two
recesses, a spherical
recess and an eliptical
recess.
• Anterior to the vestibule
sits the cochlea and is
connected to the
vestibule by the narrow
• The spherical recess is perforated
at its anterior and inferior
part,
by several minute holes (macula
cribrosa media)
for the passage
of filaments of the acoustic nerve
to the saccule

• Behind this depression is an

oblique ridge, the crista vestibuli,
the anterior end of which is named
the pyramid of the
vestibule.
This ridge bifurcates below to enclose a
small depression, the fossa cochlearis, which is
perforated by a number of holes for the passage of
filaments of the acoustic nerve which supply the
vestibular end of the cochlear duct.

• At the hinder part of the medial wall is the orifice of

• On the upper wall or roof is a transversely oval
depression, the recessus ellipticus

• The pyramid and adjoining part of the recessus

ellipticus are perforated by a number of holes
(macula cribrosa superior). The apertures in
the pyramid transmit the nerves to the utricle;
those in the recessus ellipticus the nerves to
the ampullæ of the superior and lateral
semicircular ducts.

• Macula cribrosa superior also c/as the

“Mike’s dot” marks the passageway for
superior vestibular nerve fibers to the cristae
ampullares of the lateral and superior
semicircular canals. It corresponds to the
extreme lateral aspect of the IAC, so Mike’s dot
is an important landmark in
• The vestibule contains the
Ø Utricle
Ø Saccule
• Saccule:
• Globular in shape and lies immediate posterior to the cochlea
• Anterior part exhibits an oval thickening, the macula acustica
sacculi, to which are distributed the saccular filaments of the
acoustic nerve.
• From the lower part of the saccule a short tube, the Canalis
reuniens of Hensen, passes downward and opens into the ductus
cochlearis near its vestibular extremi
• Utricle:
• Elliptical in shape and lies posterosuperiorly.
• Portion which is lodged in the recess forms a cul-de-sac, c/as the
macula acustica utriculi, which receives the utricular filaments
of the acoustic nerve
• It receives 5 openings of the three semicircular canal
• Utriculosaccular duct connects the utricle and the
saccule
• The utricle and the saccule is lined by the sensory
 Macula
• It is a flat kidney shaped gelatinous organ
consisting of neuroepithilium, supporting
cells, blood vessels and nerve fibres
• Utricular macule – lies horizontally in the floor
• Saccular macule – lies vertically on the wall
• The ciliarybundles of the sensory cells
project into the
overlying statoconial
membrane.
• The statoconialmembrane is comprised of
3 layers, as follows:
– The otoconial first layer is comprised of calcareous
particles
(otoconia), which are inorganic crystalline
deposits composed of calcium
carbonate or calcite. They vary in size from 0.5-30
mcm, with most about 5-7 mcm. The specific
gravity of the otolithic membrane is much higher
than that of the endolymph, about 2.71-2.94.
• Within the macular membrane
is the striola, a specialized
central region that has a
snowdrift-like appearance.
• In the striola, the otoconia are
very small (about 1 µm) and
the thickness of the otolithic
membranes is either reduced,
as in the utricular macula, or
increased, as in the saccular
macula.
• It has a higher concentration

Structure of the otolith organs.

A, Sacculus. B, Utriculus. C,
Composition of otoconial
membrane of the sacculus in a
section taken at the level shown in A
 Semicircular canal
• They are in three in no. lying postero-
superior to the vestibule and are at right
angles to each other
– One horizontal SCC, also c/as lateral canal
– Two vertical SCC, superior or posterior canal
• They are oriented at right angles to each
other and are situated so that the
superior and posterior
canals are at 45°
angles to
the sagittal plane,
and the horizontal canal
is
Horizontal (LC, lateral) Vertical canals (AC and PC)
canal is tilted 30 degrees are oriented at roughly 45
upward from horizontal degrees from midsagittal
•  Superior semicircular
canal
– 15 to 20 mm. in length
– vertical in direction
– placed transversely to the
long axis of the
petrous portion of the
temporal bone.

•  Posterior semicircular
canal
– vertical
– it is the longest of the
three, measuring from 18
to 22 mm
– Parallel to the the long
axis of the petrous portion
of the temporal bone
•  Lateral or horizontal
canal
– is the shortest of the Position of the right bony labyrinth of the ear in the
skull, viewed from above. The temporal bone is
considered transparent and the labyrinth drawn in
from a corrosion preparation.
 DONALDSON’S LINE
• A surgical landmark
in endolymphaticsac

surgery, is derived by
extending the
plane
of the lateral semi

circular canal so that

it bisects the
posterior
semicircular canal and

contacts the posterior

Ø Each canal forms two thirds of a circle
with a diameter of about 6.5 mm and a
luminal cross-sectional diameter of 0.4 mm
Ø Each canal has an ampullated limb,
measuring 2 mm in diameter (It contains a
saddle-shaped ridge termed the crista
ampullaris, on which lies the sensory
epithelium) and a nonampullatedlimb, which
is 1 mm in diameter.
Ø The nonampullated limbs of the posterior
and superior canals fuse to form the crus
commune.
Ø All the semicircular canals open into the
utricle through 5 openings
Ø The horizontal canal is paired with the
contralateral horizontal canal; however, the
 Crista Ampullaris
• Saddle shaped gelatinous mass located
at the ampullated end of each SCC
• Consists of a crest of sensory
epithelium supported on a mound of
connective tissue, lying at right angles
to the longitudinal axis of the canal
• Its sensory epithelium has special cells
c/as the HAIR CELLS (the sensory cells
of vestibular system)
• A bulbous, wedge-shaped, gelatinous
mass called the cupula surmounts the
crista. The cupula extends from the
surface of the cristae to the roof and
lateral walls of the membranous
• Distinct subcupular space in the region of the cupula
overlying the apex of the center of the crista This
subcupular space is believed to provide space for freedom
of movement and more sensitive responses to endolymph
flow for the stereocilia on the hair cells in the central zone.
• The specific gravity of the cupula is approximately
1.0, which is about the same as that of the endolymph.
This matching of the specific gravity of the cupula and the
endolymph is necessary to prevent the cupula from
floating upward in certain head positions and causing an
enduring nystagmus.
• Disruption of this match in specific gravity is likely
 Cellular Morphology Of The
Vestibular Sensory Epithelium
• Sensory epithelium is made up of:
– Supporting cells
– Hair cells
– Afferent nerve fibers and their synaptic terminals
– Efferent nerve fibers and their synaptic boutons.
• 1) Supporting cells
• Extend from the basement membrane to the
apical surface
• The upper part of the supporting cells contains
large numbers of round or ovoid granules. The
function of these secretory granules is uncertain,
but it is thought that they are responsible for the
formation of the cupula and otolithic membrane
• 2) Hair cells (the
sensory cells of
the vestibular
system)
– Characterised by a
bundle of stereocilia
attached to their apical
surface and grouped in
a stair-case
arrangement
– In addition, each hair
cell has a single long
kinocilium. This
kinocilium is longer
than the stereocilia and
is eccentrically located

Schematic drawing of the two types of

sensory cells in the mammalian labyrinth
showing fine structural organization of type I
• The location of kinocilium relative to the
stereocilia imparts a certain polarization to the
hair cell.
• Displacement of hair bundle
toward the kinocilium
results in an
increase
in the firing rate
of the afferent
fiber(s)
contacting the hair cell
whereas
displacement of the hair bundle away from the
kinocilium results in a decrease in firing
rate.

– Disp. Of bundle towards kino. Opening of K+

• Since the stimulation of
sensory cells by deflection of
hair bundle away or towards
kinocilium is what initiates
signal transduction , the
spatial oreintation of cilia is
such that every position in
space and every movement of
head stimulates or inhibits
certain receptors
• Horizontal canal: on the
side facing utricle
• Vertical canals: side
away from the utricle
• Otolith organs: hair
cells are in two bands
separated by striola The red arrow indicates the polaruty of
– In utricle towards the cilia
i.e each of the arrow heads points to the
direction
• 3) Vestibular nerve afferents
• All vestibular afferents have a resting
discharge rate. This enables the
afferents to respond to stimuli that
cause excitation as well as inhibition
• There are three group of afferent nerve
endings:-
– Boutons: Afferents exclusively on type II
hair cells in
• Regular discharging
• Low rotational sensitivity
– Pure Calyx: Exclusively on calyx ending on
type I cells in central zone
• Irregular discharging
 Blood supply to the vestibular
apparatus

The main blood supply to the vestibular apparatus is from the

INTERNAL AUDITORY ARTERY which in 45% of cases arises
from the Anterior cerebellar artery. It can also arise from the
Vestibular Nerve
The course of Vestibular nerve through
the internal acoustic meatus
• The vestibular (Scarpa's) ganglion
sits at the bottom of the internal
auditory meatus and acts as a relay
station for nerve fibres of the vestibular
nerve.
• It has two parts, the superior vestibular
ganglion and the inferior vestibular
ganglion
• Each vestibular nv. has 25,000 aff.
fibres which are bipolar neurons having
there cell bodies located in the scarpa’s
ganglion
• Anastomosing branches
– Voit’s anastomosis
– Oort’s anastomosis
 Central Vestibular System
• It includes the vestibular nucleus and its various
connection
• The vestibular nucleus lies on the floor of the IV
th ventricle

• The vestibular nu. has four divisions

– Superior V.N of Becheterew
– Lateral V.N of Deiters
– Medial V.N of Schwalbe
• Afferent supply to divisions of vestibular
nv. Utricle
Cristae Cerebellum
(SCC) Spinal cord
cerebellum

Cristae Utricle
Cerebellum Saccule
utricle

• Efferentsfrom
Thalamus divisions of vestibular
Thalamus
nu.
Reticulospinal
Ocular nu. tract
Vestibulospinal

Ocular nu.
Cervical Cerebellum
cord c/l V.N (med,
Cerebellum lat)
Principles of Applied Vestibular
Physiology
• Principle 1
• The vestibular system primarily
drives reflexes to maintain stable
vision and posture

• Clinical Importance: The brainstem interprets imbalances in

vestibular input resulting from pathological processes in the
same way that it interprets imbalances resulting from
VESTIBULO OCULAR REFLEX
• Helps in gaze fixation and keeps the object on
fovea with change in head position
VESTIBULO OCULAR REFLEX
• The polarity of stereociliary bundles in the right
horizontal canal is a mirror image of the
arrangement on the left, so
 VESTIBULO SPINAL REFLEX
• Pathway :–
Lateral and medial vestibulo spinal tract
Reticulospinal tract
• Principle 2
• By Modulating the Non-Zero Baseline
Firing of Vestibular Afferent Nerve Fibers,
Semicircular Canals Encode Rotation of the
Head, and Otolith Organs Encode Linear
Acceleration and Tilt

– Semicircular canals primarily sense rotational

acceleration of the head.
– Utricle and Saccule primarily sense linear
acceleration in horizontal and vertical
directions, respectively.
A.The cupula spans the lumen of the
ampulla from the crista to the
membranous labyrinth.
B. Head acceleration exceeds
endolymph acceleration.
The relative flow of endolymph
in the canal is therefore opposite
to the direction of head
acceleration. This flow produces
a pressure across the elastic
A, At rest there is baseline release of
excitatory
glutamate from the hair cell synapses
B, Hair cells are depolarized
C, This occurs because the stretched tip
links open cationic channels The influx of
potassium ions raises the hair cell's
membrane potential.
D, Activation of voltage-sensitive
calcium channels in the basolateral
membrane of the cell.
• Principle 3
• Stimulation of a Semicircular Canal
Produces Eye Movements in the Plane of
that Canal
• The semicircular canals are perpendicular
to each other and the canals in two
labyrinth are arranged in complemantary
coplanar planes
– Two horizontal canals are roughly in one
plane, which is nearly horizontal when
the head is in an upright position
– The left anterior canal is roughly coplanar
with the right posterior canal in the left-
anterior-right-posterior (LARP) plane
– The right anterior canal is roughly
coplanar with the left posterior canal in
• Clinical Importance:
• BENIGN PAROXYSMAL
POSITIONING VERTIGO
(BPPV).
– In the most widely accepted current model of
BPPV, otolith crystals displaced from the
utricular otoconial mass come to rest in the
posterior semicircular canal
– When the patient lies down and turns the
head toward the affected side, aligning the
posterior canal with the pull of gravity (THE
DIX-HALLPIKE MANEUVER), the otolith crystals Excitation of the left
fall toward what is now the "bottom" of the posterior canal (PC)
canal. by moving canaliths
in
– As the otoliths fall, they push endolymph benign paroxysmal
ahead of them, causing cupular deflection postioning vertigo
and exciting hair cells on the posterior canal (PC-BPPV) causes
crista. slow phase eye
– Nystagmus develops during the time that movements
downward in the
endolymph moves.
– Ewald's first law predicts the direction of that
• Principle 4
• A Semicircular Canal Is Normally Excited
by Rotation in the Plane of the Canal
Bringing the Head Toward the Ipsilateral
Side
• Keeping track of ampullopetal and ampullofugal flows is
unnecessary, instead one needs to only recall that a
semicircular canal is excited by rotation in the plane of the
canal bringing the head toward the ipsilateral side.
– The right horizontal canal is excited by turning the head toward
the right in the horizontal plane.
– The right anterior canal is excited by pitching the head nose
down while rolling the head toward the right in a plane 45
degrees off of the midsagittal plane.
– The right posterior canal is excited by pitching the head nose
up while rolling it toward the right in a plane 45 degrees off of
the midsagittal plane

• Clinical importance: This principle

eliminates the need to memorize the
• Principle 5
• Any Stimulus that Excites a Semicircular
Canal's Afferents will Be Interpreted as
Excitatory Rotation in the Plane of that
Canal

• A pathological asymmetry in input from canals causes

the eyes to turn in an attempt to compensate for the
"perceived" head rotation.
• However, given the mechanical constraints imposed
by the extraocular muscles, the eyes cannot continue
to rotate in the same direction that the canals
command for very long. Instead, rapid, resetting
movements occur, taking the eyes back toward their
neutral positions in the orbits. The result is
nystagmus, a rhythmic, slowly forward-quickly
backward movement of the eyes.
• This nystagmus has two phases
– Slow vestibular driven phase
– Fast resetting movement
• By convention it is the fast component which is
• CALORIC TEST

Density ↓ ed Density ↑ ed

Lighter fluid Heavier fluid

moves up moves away
towards from ampulla
Stimulation of Inhibition of
hair cells and hair cells and
VOR VOR
Eye moves to Eye moves to
opp. side (slow same side
ph.) (slow ph.)
NYSTAGMUS NYSTAGMUS
TO SAME SIDE TO OPP. SIDE
• FISTULA TEST
• In cases of fistula in HCC air pressure
changes in external canal is
transmitted to HCC producing
NYSTAGMUS

• Positive test
– Erosion of lateral SCC
– Fenestration operation
• Negative test
– Normally
– Dead labyrinth
• SUPERIOR CANAL DEHISCENCE
SYNDROME
• Another example of a disorder causing
isolated stimulation of a single semicircular
canal
• When the sup. SCC is eroded a third window
is created through which loud sounds
stimulate the SCC
– Applying a loud sound to the left ear through a
headphone causes her to develop vertigo and
nystagmus. When she is directed to look 45 degrees to
her left, one observes that the slow phases of her
nystagmus move her pupils up
– In this case, the eyes are moving in the LARP plane and
in the direction anticipated for excitation of the left
anterior canal or inhibition of the right posterior canal.
Since only the left ear is receiving the sound stimulus,
the problem must lie in the left anterior superior canal.
• Principle 6
• For High Accelerations, Head Rotation in
the Excitatory Direction of a Canal Elicits a
Greater Response than Does the Same
Rotation in the Inhibitory Direction

• Movement of endolymph in the "on" direction for

a canal produced greater nystagmus than an
equal movement of endolymph in the "off"
direction.
• This is called as Ewald's Second Law, indicates
an excitation-inhibition asymmetry
• This can occur at multiple levels
• Hair cells
• Vestibular Nv. Aff.
• HEAD THRUST TEST
• In it the examiner simply asks the subject to stare
at the examiner's nose while the examiner turns
the subject's head quickly along the excitatory
direction for one canal.

• If the function of that canal is diminished, the

VOR will fail to keep the eye on target, and the
examiner will see the patient make a refixation
saccade after the head movement is completed,
thus inducing nystagmus to same side.

• In contrast, when the head thrust is in the

excitatory direction of an intact canal (and nerve),
A through C show a head thrust to the left, exciting the left horizontal
canal (HC). The eyes stay on the examiner's nose throughout the
maneuver, indicating normal left HC function.
D through F show a head thrust to the right, exciting the right HC. The
eyes do not stay on target, but move with the head during the head
thrust (D through E). A refixation saccade brings the eyes back on
target after completion of the head movement (F). This is a "positive"
head thrust sign for the right HC, indicating hypofunction of that canal
• Principle 7
• The Response to Simultaneous Canal
Stimuli Is Approximately the Sum of the
Responses to Each Stimulus Alone
– Most of the rotations of the head stimulate two
or all three SCC pairs. The motion of endolynph
in each canal will detemine the degree to
which the hair cell in that canal are stimulated
– Max. motion of endolymph will occur in that
canal which is relatively more in the plane of
head movt.
– Thus the eye movt. +nt due to any head movt.
is the sum of vectors from every stimulated
canal
A, Excitation of the LH canal
causes rightward slow phases due
mainly to strong activation of right
LR and left MR.
B, Excitation of the LA canal
causes upward/clockwise (from
patient's perspective) slow phases,
due to combined action of the right
IO and SR and the left SO and SR.
C, Excitation of the LP canal causes
downward/clockwise (from
patient's perspective) slow phases,
due to combined action of the right
IO and IR and the left SO and IR.
D Equal stimulation of LH and RH
canals elicits antagonistic
contraction of MR and LR
bilaterally, yielding no nystagmus.
E Combined equal excitation of LA
and LP canals excites muscle
activity that is the sum of each
canal's individual effect; upward
and downward pulls cancel,
resulting in a purely clockwise
nystagmus. F Combined equal
excitation of all three left canals
• Clinical Implications:

• This nystagmus as seen in fig. F can be seen when the

labyrinth is irritated
– Early in an attack of ménière's disease
– After stapedectomy procedures
– Early in the course of viral labyrinthitis

• “Fetter and Dichgans” measured 3D eye movements in

16 patients with spontaneous nystagmus 3 to 10 days
after the onset of vestibular neuritis.
– Their spontaneous nystagmus axes clustered
between the direction expected from hypofunction of
the horizontal canal and the direction expected from
hypofunction of the anterior canal on the affected
side.
– Hypofunction of the posterior canal did not seem to
contribute to the nystagmus, and head thrusts in the
plane of the ipsilateral posterior canal showed
preserved function.
• Principle 8
• Nystagmus Due to Dysfunction of
Semicircular Canals Has a Fixed Axis and
Direction with Respect to the Gaze
• Clinical Implications:
– This principle helps to distinguish nystagmus
resulting from a peripheral vestibular disorder
from nystagmus resulting from a central
disorder.
• In peripheral disorder:- The direction or axis remains
the same
• In central disorder:- The axis or direction of
nystagmus may change depending on the direction of
gaze.
• It is important to note that the magnitude
• Principle 9:
• Brainstem Circuity Boosts Low-Frequency
VOR Performance Through "Velocity
Storage" and "Neural Integration“

• Clinical Implications
– Post-rotatory nystagmus.
– Head-shake nystagmus.
– Alexander's Law
HEAD-SHAKE NYSTAGMUS
• If the head is rotated side to side in the
horizontal plane in normal subjects, the
velocity storage mechanism is charged
equally on both sides.

• There is no post-rotatory nystagmus as the

stored velocities decay at the same rate on
either side.

• However, nystagmus does occur after head

shaking in subjects with unilateral vestibular
hypofunction.

• When the head stops rotating, the

ALEXANDER’S LAW. After
unilateral vestibular loss, a central
process (called the “leaky
integrator”) contributes to eye
motion and nystagmus by allowing
the eye to drift to center,

When the eyes look to the

direction of the
fast phase (right, B), the leaky
integrator causes the eye to drift
to the left. This drift adds to the
vestibular slow phase, and the net
slow phase velocity (SPV)
increases.

When the eyes look to the

direction of the slow phase (left,
C), the leaky integrator causes the
• Principle 10
• The Utricle Senses Both Head Tilt and
Translation, but Loss of Unilateral Utricular
Function Is Interpreted by the Brain as a
Head Tilt to the Opposite Side
• Clinical Implications:
Ø An isolated loss of utricular nerve activity elicits a
stereotyped set of static responses called the
OCULAR TILT REACTION
– (1) A head tilt toward the lesioned side
– (2) A disconjugate deviation of the eyes such that the pupil on
the intact side is elevated and the pupil on the lesioned side is
depressed (a so-called skew deviation)
– (3) A static conjugate counter roll of the eyes—rolling the
superior pole of each eye away from the intact utricle
 • Each of these signs can be
understood as the brain's
compensatory response to a
perceived head tilt toward
the intact utricle.

• The ocular tilt reaction can

also occur from interruption
of central otolithic pathways
as, for example, in multiple
sclerosis.

• The full ocular tilt reaction is

not often observed in
The otolith tilt reaction
for peripheral vestibular lesions
loss of left utricular because the brainstem
compensates for some
• Principle 11:
• Sudden Changes in Saccular Activity
Evoke Changes in Postural Tone
– The saccule is almost planar and lies in a parasagittal
orientation.

– Hair cells of the saccule, are polarized so that they are

excited by otoconial mass displacements away from the
striola, and sense linear accelerations.

– Thus, sudden excitation of hair cells across the saccular

macula would likely be interpreted by the brain as a
sudden loss of postural tone (i.e., falling). The
appropriate compensatory reflex would be one that
activates the trunk and limb extensor muscles and
relaxes the flexors to restore postural tone.
• Saccular excitation probably underlies the test of
VESTIBULAR-EVOKED MYOGENIC POTENTIALS
(VEMPS)
– VEMPs are transient decreases in flexor muscle
electromyographic (EMG) activity evoked by loud acoustic
clicks or tones applied to the ear.
– Sufficiently loud sounds applied to the ear excite saccular
afferents. The predicted reflexive response would include
relaxation of flexor muscles.
– Sternocleidomastoid is the preffered site
– Because the saccule is the only end organ that mediates
VEMP responses, absence of VEMP responses may
indicate saccular dysfunction

• Postural tone change that may be related to saccular

activity is the drop attack, also know as the
"OTOLITHIC CRISIS OF TUMARKIN,"
– It is a dramatic loss of postural tone that can occur in
ménière's disease independent of other vestibular
symptoms at the time of the fall.
• Principle 12
• The Normal Vestibular System Can
Rapidly Adjust the Vestibular
Reflexes According to the Context,
but Adaptation to Unilateral Loss of
Vestibular Function May Be Slow and
Susceptible to Decompensation
 A N
T H
K
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