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Dizziness

I. History

A. Do not suggest symptoms (take an open-ended history)

B. Recognize that some patients may use medical terms (eg vertigo) when they really mean dizziness

C. All cultures have some term which corresponds to dizziness

D. Are there concomitant hearing (eg deafness or tinnitus) or ear (eg stuffiness or mastoid discomfort) suggesting peripheral disease dizziness, diziness, dizzines, dizines

E. Are there concomitant brain stem symptoms (eg diplopia, dysarthria, visual disturbance ataxia)

F. Remember disease in the VIII nerve (in the internal auditory meatus or in the cerebellopontine angle) is 

II. Physical Examination

A. General Neurologic Examination

1. Examine the ear (is there a ruptured tympanic membrane or otorrhea?)

2. Orthostatic signs

3. ? extrapyramidal signs

4. ? Romberg's sign

5. Test gait

B. Neurologic Examination with Particular Reference to CN VIII

1. Vestibular

a. Dizziness simulation battery

(1) orthostatic blood pressure and pulse

(2) valsalva

(3) carotid sinus pressure

(4) hyperventilation for three minutes

b. Spontaneous nystagmus: factors which favor peripheral nystagmus

(1) unidirectional in a single head position

(2) horizontal or horizonto-rotatory

(3) has fast and slow component (jerk type)

(4) increases when looking toward fast phase (Alexander's law)

(5) symmetrical in both eyes

(6) enhanced by eye closure

c. Positional nystagmus - the Nylen-Barany maneuver

d. The fistula test, particularly if history of recent or remote head trauma

2. Cochlear vs. Retrochochlear Sensorineural Hearing Loss

a. Clinical exam and/or audiometry

(1) Pure tone hearing (watch tick, finger rub, tuning forks)

(2) Speech discrimination

(3) Recruitment

(4) Short increment sensitivity

(5) Tone decay

III. Laboratory Studies

A. Audiometry

B. Skull X-Ray with internal auditory meatus tomogram

C. Electronystagmography (ENG) and Posturography

D. Brain stem auditory evoked responses (BAERS)

E. Magnetic resonance imaging and angiography

IV. Differential Diagnosis

A. Vertigo (ie illusory (rarely hallucinatory) sense of movement)

1. Anatomy and physiology of vestibular function, nystagmus and vertigo

2. Peripheral Disease

a. Cochlear

(1) Labyrinthitis - perhaps immune mediated

(2) Vestibular neuronitis - perhaps immune mediated

(3) Meniere's disease

(4) Trauma (vestibular concussion) - not "postconcussion" syndrome

(5) Drugs (eg aminoglycosides)

(6) Syphilis

(7) Benign positional vertigo

(a) Otolithiasis

(b) Perilymphatic fistula

b. Retrocochlear

(1) Acoustic schwannoma (intracanalicular or in CP angle)

(2) Meningioma

(3) Trauma (severe with basilar skull fracture)

3. Central Diseases

a. Vascular (eg vertebrobasilar artery disease)

b. Migraine (Basser syndrome)

c. Demyelinating (eg multiple sclerosis - usually with INO)

d. Drugs (eg anticonvulsants, alcohol and hypnotics)

e. ?Microvascular compression syndromes

f. Seizures (rare)

4. Treatment

a. Antihistamines (eg, meclizine, etc.)

b. Phenothiazine (ie promethazine)

c. Belladonna alkaloids (eg scopolamine)

d. Stimulants (eg Ritalin)

e. Benzodiazepines

f. ?Diuretics for Meniere's disease

g. ?Vestibular deconditioning exercises, particularly for benign positional vertigo

B. Faint (near syncope)

1. Orthostatic hypotension

a. Environmental phenomena (eg high ambient temperature)

b. Hypovolemia

c. Vasodilators (eg alcohol, antihypertensives)

d. Alpha blockers (eg tricyclics)

e. Autonomic neuropathy (eg diabetes, amyloid)

2. Arrhythmia (relatively rare)

3. Valvular and subsalvular disease (eg AS; ASH)

4. Vasovagal attack (ie. neurocardiogenic near-syncope)

5. Hypersensitive carotid sinus

6. Hyperventilation

C. Dysequilibrium

1. Multiple sensory deficits

2. Gait disorder

D. Ill-defined light-headedness (true dizziness)

1. Anxiety states

2. Metaphorical dizziness (meaning depression, chronic fatigue, etc.)

3. Psychosis (rare)

4. Conversion symptom (rare)

5. Malingering (rare)

 

References

Drachman DA, Hart CW. An Approach to the Dizzy Patient. Neurology 22:323, 1999.

Roydhouse N. Vertigo and Its Treatment. Drugs 7:297, 2000.

Weiss AD. Neurological Aspects of the Differential Diagnosis of Vertigo. Ann Oto Rhinol Laryngol 77:216, 1968.

Wolfson RJ (ed). Symposium on Vertigo. Otolaryngologic Clinics of North America 6:1, 1999.

Weiss HD. Dizziness in Manual of Neurologic Therapeutics, 5th edition,

Samuels, MA (ed.) Boston: Little-Brown, 1995, pps 58-77.

Vestibular Disorders Association, 1015 N.W. 22nd Avenue, D230, Portland, OR 97210-3079

Lempert T, et al: Syncope: A videometric analysis of 56 episodes of transient cerebral

hypoxia. Ann Neurol 1994;36:233-237.

Key: + = mild; + + = moderate: + + + = severe.