Vertigo approach

By Dr Sohrab RabieiBy Dr Sohrab Rabiei 11

Clinical evaluation & ApproachClinical evaluation & Approach
Dr Sohrab RabieiDr Sohrab Rabiei
otolaryngologistotolaryngologist

Clinical evaluation & ApproachClinical evaluation & Approach
 HistoryHistory
 Physical examinationPhysical examination
 TestingTesting - laboratory & office- laboratory & office
 RadiologicRadiologic
 Differential diagnosisDifferential diagnosis
 Diagnostic criteriaDiagnostic criteria
 AcuteAcute care/hospitalizationcare/hospitalization
 Medical therapyMedical therapy
 Invasive approachInvasive approach
 ComplicationComplication
 Especial circumstancesEspecial circumstances
 Consult and referConsult and refer
 PrognosisPrognosis
 Pt educationPt education
 Follow upFollow up

HistoryHistory
1)1) Attempt to define the true qualitative nature ofAttempt to define the true qualitative nature of
the symptom complex by asking for an exactthe symptom complex by asking for an exact
description of what the patient means bydescription of what the patient means by
"dizziness," without biasing the outcome by"dizziness," without biasing the outcome by
providing descriptive wordsproviding descriptive words
22))Ask about the temporal course of the symptomsAsk about the temporal course of the symptoms..

3)Ask about associated symptoms, such as3)Ask about associated symptoms, such as
tinnitus, hearing loss, double vision, numbness,tinnitus, hearing loss, double vision, numbness,
nausea, or vomiting.nausea, or vomiting.
4)Review the patient's general medical history4)Review the patient's general medical history
and records for evidence of hypertension,and records for evidence of hypertension,
diabetes mellitus, heart disease, endocrinediabetes mellitus, heart disease, endocrine
disease, or psychiatric illness.disease, or psychiatric illness.

5) Review the patient's history of drug use5) Review the patient's history of drug use
(prescription, OTC, herbal) and any adverse(prescription, OTC, herbal) and any adverse
effectseffects ..
6) Ask about precipitating factors such as6) Ask about precipitating factors such as
trauma, undue stress, or apparent viraltrauma, undue stress, or apparent viral
infectioninfection..

A minimum vertigo history shouldA minimum vertigo history should
address the following:address the following:
 the duration of the individual attack, that is, hoursthe duration of the individual attack, that is, hours
versus daysversus days
 frequency, that is, daily versus monthlyfrequency, that is, daily versus monthly
 the effect of head movements, that is, worse, better, orthe effect of head movements, that is, worse, better, or
no effectno effect
 inducing position or posture, for example, rolling ontoinducing position or posture, for example, rolling onto
the right side in bedthe right side in bed
 associated aural symptoms such as hearing loss andassociated aural symptoms such as hearing loss and
tinnitustinnitus
 concomitant or prior ear disease and/or ear surgeryconcomitant or prior ear disease and/or ear surgery

Vertigo durationVertigo duration
1)Vertigo lasting minutes to1)Vertigo lasting minutes to
hours :hours :
a. Idiopathic endolymphatic hydropsa. Idiopathic endolymphatic hydrops
(meniere's disease)(meniere's disease)
b. Secondary endolymphaticb. Secondary endolymphatic
hydropshydrops
(1) Otic syphilis(1) Otic syphilis
(2) Delayed endolymphatic(2) Delayed endolymphatic
hydropshydrops
(3) Cogan's disease(3) Cogan's disease
(4) Recurrent vestibulopathy(4) Recurrent vestibulopathy
2)Vertigo lasting seconds:
benign paroxysmal positional vertigobenign paroxysmal positional vertigo
3)Vertigo lasting days:
vestibular neuronitisvestibular neuronitis
4)Vertigo of variable duration:
a. Inner ear fistulaa. Inner ear fistula
b. Inner ear traumab. Inner ear trauma
(1) Nonpenetrating trauma(1) Nonpenetrating trauma
(2) Penetrating trauma(2) Penetrating trauma
(3) Barotrauma(3) Barotrauma

Physical ExaminationPhysical Examination
1) Perform a general physical examination,1) Perform a general physical examination,
focusing on orthostatic measurements andfocusing on orthostatic measurements and
other cardiovascular signs.other cardiovascular signs.
2) Evaluate the patient's motor coordination2) Evaluate the patient's motor coordination
and sensory function for the presence ofand sensory function for the presence of
unsteady gait, past-pointing, or ataxia.unsteady gait, past-pointing, or ataxia.

3) Perform the Romberg test (using3) Perform the Romberg test (using
necessary precautions to protect thenecessary precautions to protect the
patient from injury) to assesspatient from injury) to assess
proprioceptive function.proprioceptive function.
4) Examine the eyes (preferably in a4) Examine the eyes (preferably in a
dim light) for nystagmus.dim light) for nystagmus.

5) As a means to diagnose BPPV in patients5) As a means to diagnose BPPV in patients
presenting with vertigo, perform the Dix-presenting with vertigo, perform the Dix-
Hallpike provocative maneuver .Hallpike provocative maneuver .
6) Examine the patient for middle-ear6) Examine the patient for middle-ear
disease or hearing loss using an otoscopedisease or hearing loss using an otoscope
and the Rinne test.and the Rinne test.

Bedside examinationBedside examination
 General ENT examinationGeneral ENT examination
 PTA and audiologic evaluationPTA and audiologic evaluation
 Cranial nerve examinationCranial nerve examination

 Spontaneous NystagmusSpontaneous Nystagmus
 Head-shaking nystagmusHead-shaking nystagmus
 Positional nystagmusPositional nystagmus
 Dynamic visual acuityDynamic visual acuity
 Valsalva induced nystagmusValsalva induced nystagmus
 HyperventilationHyperventilation
 Nystagmus due to sound or pressureNystagmus due to sound or pressure
TullioTullio (vertigo induced by sound )(vertigo induced by sound )
Henneberg’sHenneberg’s ( vertigo induced by pressure )( vertigo induced by pressure )

Testing : office and laboratoryTesting : office and laboratory
1) Target laboratory tests to suspected1) Target laboratory tests to suspected
conditions .conditions .
2) Consider requesting electronystagmography2) Consider requesting electronystagmography
to evaluate vestibular function in patients withto evaluate vestibular function in patients with
questionable/complex disorders.questionable/complex disorders.
3) Consider computerized rotational testing3) Consider computerized rotational testing
to quantitate bilateral reduced vestibularto quantitate bilateral reduced vestibular
function, such as occurs with drug ototoxicty.function, such as occurs with drug ototoxicty.

6) Consider brainstem auditory evoked-6) Consider brainstem auditory evoked-
response testing in patients withresponse testing in patients with
unexplained hearing loss.unexplained hearing loss.
5) Perform an audiogram in patients with5) Perform an audiogram in patients with
possible hearing loss.possible hearing loss.
4) Consider requesting posturography, if4) Consider requesting posturography, if
available, to quantify the Romberg test inavailable, to quantify the Romberg test in
patients with equivocal balance disorderspatients with equivocal balance disorders..

Basic screeningBasic screening
1-Blood glucose level Possible diabetes1-Blood glucose level Possible diabetes
2- Complete blood count Possible infection or2- Complete blood count Possible infection or
anemiaanemia
3- Electrolyte levels Possible imbalance :3- Electrolyte levels Possible imbalance :
hyponatremia, hypocalcemiahyponatremia, hypocalcemia
4-Thyroid-function test (e.g., serum TSH, T4)4-Thyroid-function test (e.g., serum TSH, T4)
Possible hypothyroidismPossible hypothyroidism
5- Lipid levels Possible hyperlipidemia5- Lipid levels Possible hyperlipidemia

RadiologicRadiologic
1)1) Obtain a CT head scan in patients withObtain a CT head scan in patients with
suspected central nervous system pathology.suspected central nervous system pathology.
2) Obtain a head MRI for patients with2) Obtain a head MRI for patients with
persistent symptoms that suggest a disorderpersistent symptoms that suggest a disorder
of the central nervous system.of the central nervous system.

Differential DiagnosisDifferential Diagnosis
 First, based on the history andFirst, based on the history and
physical examination findings,physical examination findings,
determine whether the patient'sdetermine whether the patient's
dizziness is most likely to bedizziness is most likely to be
caused by a peripheral, central, orcaused by a peripheral, central, or
systemic disordersystemic disorder

Third, if the diagnosis is still notThird, if the diagnosis is still not
obvious, focus further investigationsobvious, focus further investigations
on the limited number of remainingon the limited number of remaining
diagnostic possibilities.diagnostic possibilities.
Second, compare the clinical findingsSecond, compare the clinical findings
with the characteristic manifestations ofwith the characteristic manifestations of
each of the diseases within the most likelyeach of the diseases within the most likely
category (i.e., peripheral, central, orcategory (i.e., peripheral, central, or
systemic).systemic).

Diagnostic CriteriaDiagnostic Criteria
 Based on the clinical history, physicalBased on the clinical history, physical
examination findings (especiallyexamination findings (especially
nystagmus), and laboratory test results (ifnystagmus), and laboratory test results (if
needed), classify the cause of dizzinessneeded), classify the cause of dizziness
into one of three categories (peripheral,into one of three categories (peripheral,
central, or systemic) . Then, if possible,central, or systemic) . Then, if possible,
make a specific diagnosis based on themake a specific diagnosis based on the
same information.same information.

Acute Care/HospitalizationAcute Care/Hospitalization
 Immediately hospitalize patients withImmediately hospitalize patients with
new onset of vertigo accompanied bynew onset of vertigo accompanied by
neurologic signs and symptoms suchneurologic signs and symptoms such
as double vision, limb numbness, oras double vision, limb numbness, or
slurred speech.slurred speech.

Medical TherapyMedical Therapy
 Treat the underlying disorder inTreat the underlying disorder in
patients with a definitive diagnosis.patients with a definitive diagnosis.
Consider the use of vestibularConsider the use of vestibular
suppressants for symptomatic treatment ofsuppressants for symptomatic treatment of
dizziness of probable peripheral origindizziness of probable peripheral origin

Prescribe exercise therapy, such as anPrescribe exercise therapy, such as an
Epley-type maneuver, as therapy in allEpley-type maneuver, as therapy in all
patients with BPPV.patients with BPPV.

Invasive ApproachesInvasive Approaches
 Consider surgery as a last resort forConsider surgery as a last resort for
patients with clearly defined severe attackspatients with clearly defined severe attacks
of peripheral vestibulopathy that areof peripheral vestibulopathy that are
refractory to medical therapy.refractory to medical therapy.
Direct surgical treatment ofDirect surgical treatment of
central causes of dizziness to thecentral causes of dizziness to the
underlying diagnosis.underlying diagnosis.

Special CircumstancesSpecial Circumstances
 Be aware of syncope, presyncope, andBe aware of syncope, presyncope, and
severe lightheadedness as commonsevere lightheadedness as common
accompaniments of pregnancy.accompaniments of pregnancy.
Be alert for faintness orBe alert for faintness or
lightheadedness in patients with medicallightheadedness in patients with medical
conditions that affect blood pressure.conditions that affect blood pressure.

When to Consult or ReferWhen to Consult or Refer
Refer to a otolaryngologist PatientsRefer to a otolaryngologist Patients
with progressive, disabling Meniere'swith progressive, disabling Meniere's
diseasedisease
Refer to a otolaryngologist PatientsRefer to a otolaryngologist Patients
with BPPVwith BPPV
Consider referring patientsConsider referring patients
with cardiovascular findings towith cardiovascular findings to
a cardiologist.a cardiologist.

 Refer to a neurologist patients with centralRefer to a neurologist patients with central
nervous system signs or symptoms:nervous system signs or symptoms:
- Patients with central vestibular, cerebellar,Patients with central vestibular, cerebellar,
or focal neurologic findings, who shouldor focal neurologic findings, who should
undergo further neurologic testingundergo further neurologic testing
- Atypical nystagmus or central nystagmusAtypical nystagmus or central nystagmus

If the patient has psychiatric problemsIf the patient has psychiatric problems
(e.g., panic disorder or depression) that do(e.g., panic disorder or depression) that do
not sufficiently respond to simplenot sufficiently respond to simple
reassurance and standard drugreassurance and standard drug
management, consider referral to amanagement, consider referral to a
psychiatristpsychiatrist..

Patient Education /General AdvicePatient Education /General Advice
 If appropriate, instruct patients withIf appropriate, instruct patients with
BPPV on how to perform exerciseBPPV on how to perform exercise
therapy at home.therapy at home.
Reassure patients with peripheralReassure patients with peripheral
vestibulopathy that most symptomsvestibulopathy that most symptoms
improve with time.improve with time.

To help relieve the side effects of anxietyTo help relieve the side effects of anxiety
and depression, extra understanding andand depression, extra understanding and
patience should be used with patients withpatience should be used with patients with
chronic dizziness who have seen manychronic dizziness who have seen many
physicians.physicians.

Characteristics of Peripheral Versus Central Positional Vertigo
Characteristic Peripheral positional vertigo Central positional vertigo
Latency (time to onset of vertigo
or nystagmus)
0-40 sec (mean, 7.8 sec) Begins immediately
Duration (signs and symptoms of
single episode)
<1 min Symptoms may persist
Fatigability or habituation
(lessening signs and symptoms
with repetition of provocative
maneuver)
Yes (in 87%) No
Nystagmus direction Direction fixed, torsional, upward,
upper pole of eyes toward ground
Direction changing, variable
Intensity of signs and symptoms Severe vertigo, marked nystagmus,
systemic symptoms such as
nausea
Usually mild vertigo, less
intense nystagmus, rare nausea
Reproducibility Inconsistent More consistent

Differential Diagnosis of Typical Causes of Dizziness/Vertigo
Clinical findings Diagnosis Further tests and
interpretation
Brief episodes of vertigo associated with a
change in head position
Benign paroxysmal
positional vertigo
Positive Dix-Hallpike test with a
typical rotary nystagmus
Recurrent attacks of severe vertigo
accompanied by vomiting, tinnitus,
fluctuating hearing loss, and a sensation of
ear fullness
Meniere's disease Audiometry;
electronystagmography may be
useful in patients with atypical
manifestations
Transient clumsiness, loss of vision,
perioral numbness, diplopia, ataxia,
dysarthria
Brain stem ischemia MRI; MR or conventional
angiography may be needed;
neurologic findings (often subtle)
and characteristic types of
nystagmus are diagnostic clues
Sudden, severe vertigo of longer duration,
sometimes preceded by a upper respiratory
tract infection
Vestibular neuronitis Typical nystagmus, absent
response to caloric stimulation
on one side--absence on both
sides suggests drug or alcohol
etiology

Attacks last a few minutes to 1 hr; may or may
not be associated with headache
Migraine None necessary if symptoms meet
standard criteria for migraine
headaches and neurological
examination normal
Recurrent lightheadedness when the patient
first stands up
Orthostatic hypotension Check blood pressure before and
after standing.
Recurrent attacks that last minutes and are
associated with high anxiety and
hyperventilation
Panic attacks None necessary if patient meets
standard psychiatric criteria for
panic attacks or another anxiety
disorder
Progressive hearing loss and tinnitus, possibly
accompanied by mild vertigo
Eighth-nerve tumor Audiometry, brainstem auditory
evoked response test, MRI
Disorientation or disequilibration worsened by
walking or standing, often in elderly patients
Multiple sensory deficit Assess vision, hearing, motor
coordination (e.g., gait, Romberg),
and somatosensory system (e.g.,
peripheral neuropathy)

Diagnostic Criteria for Benign Paroxysmal Positional Vertigo
Vertigo associated with a characteristic mixed torsional and vertical
nystagmus provoked by the Dix-Hallpike test
A latency (typically of 1-2 sec) between the completion of the Dix-
Hallpike test and the onset of vertigo and nystagmus
Paroxysmal nature of the provoked vertigo and nystagmus (i.e., an
increase and then a decline over a period of 10-20 sec)
Fatigability (i.e., a reduction in vertigo and nystagmus if the Dix-
Hallpike test is repeated)

Potential Tests for Patients with Dizziness/Vertigo
Findings/clinical scenario Test Interpretation/reason for
test
Laboratory tests
Basic screening Thyroid-function test (e.g.,
serum TSH, T4)
Possible hypothyroidism
Blood glucose level Possible diabetes
Complete blood count Possible infection or anemia
Electrolyte levels Possible imbalance, e.g.,
hyponatremia, hypocalcemia
Lipid levels Possible hyperlipidemia
Hearing fluctuation Serologic testing for syphilis Possible neurosyphilis

History of syncope or
presyncope
Electrocardiogram Possible cardiomyopathy,
arrhythmia
Rhythm strip Possible arrhythmia
Holter monitor Possible infrequent arrhythmia
Echocardiography Possible cardiomyopathy, valvular
lesion
Carotid Doppler
examination
Possible carotid artery stenosis

Suspected vestibular
abnormality: e.g., neuronitis,
Meniere's disease, or peripheral
vestibulopathy
ENG Helpful in determining whether
abnormality is unilateral or bilateral,
and distinguish between peripheral
and central disorders. Sensitivity
69%-74%; specificity 50% or lower.
Bilateral vestibular loss,
suspected ototoxicity
Rotational testing Helpful in determining response
patterns, and for assessing possible
bilateral ear injury when ototoxicity
is suspected
Patients who have more than ear
disease or in whom malingering
is suspected
Posturography Quantifies Romberg test and helps
identify defective system or to
exclude organic disease
Suspected hearing loss Audiogram Hearing loss may suggest acoustic
tumor in the affected ear or
Meniere's disease (especially if
fluctuating). Acoustic tumors may
cause a disproportionate loss of
speech discrimination in relation to
the pure-tone audiogram.
Suspected acoustic neuroma Brainstem auditory-evoked
response testing
May help identify lesions of the
eighth nerve and brainstem;
relatively low sensitivity but good
specificity.

Radiologic tests
Suspected central
pathology
CT head scan More sensitive than plain skull films,
but less sensitive than MRI
Significant neurologic
abnormalities on physical
examination
MRI with
gadolinium
contrast
Can identify small tumors close to
the tissue-bone interface (coronal
and sagittal reconstructions); also
useful in diagnosing multiple
sclerosis [Figure 8] and cerebellar
infarction.

Classifying Dizziness Based on Symptoms
Type of dizziness Suggestive symptoms
Peripheral True spinning vertigo, dizziness
accompanied by tinnitus or fluctuating
hearing lossa
Central Clumsiness, dysequilibration, facial
weakness or numbnessa
Systemic Lightheadedness, faintness, grayed-out
vision

Thanks for your attentionThanks for your attention
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Vertigo approach

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