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A Practical Approach to Dizziness

Overview

  • Dizziness is a common complaint. Assessment is often daunting and challenging.
  • Diagnosis is usually made on: history, history, history.
  • Diagnosis is usually confirmed by: physical examination and investigations.

Example: Benign Paroxysmal Positional Vertigo (BPPV).

KEY: History begins by trying to understand what the patient means by “dizziness”.

What patients may mean by “Dizziness”

  • Vertigo
  • Dysequilibrium
  • Light-headedness

Vertigo

  • Definition: illusion of motion (subjective vs objective).
  • Types:
    • Rotatory (suggests semicircular canal problem)
    • Linear (suggests otolith organ problem)
    • Floating

Dysequilibrium

  • Definition: inability to maintain the centre of gravity. “On a boat”; imbalance, falling, stumbling.
  • Causes:
    • Vestibular (peripheral or central)
    • Non-vestibular:
      • Sensory (proprioception/sensation)
      • Motor (muscle weakness/arthritis)

Light-headedness

  • Definition: similar to pre-syncope symptoms (e.g., sitting up quickly).
  • Cause: NOT vestibular. Consider cardiac, vascular (VBI), vasovagal, metabolic, hyperventilation. Try to simulate by hyperventilating if safe.

The History

“I understand you have been referred to me because you have dizziness, please tell me what you feel when you have this sensation and let us not use this word.”

Attack characteristics

  • Initial attack: date, duration, nature
  • Last attack: date, duration (seconds/minutes/hours), nature
  • Frequency: per day/week/month
  • Precipitating factors: event, position, exertion
  • Relieving factors: position, medications

Associated symptoms

Otologic:

  • Hearing loss
  • Tinnitus
  • Ear fullness/pressure

Non-otologic:

  • Visual disorientation; intolerance of visual motion; disruption of focusing and depth perception
  • Oscillopsia: movement of horizon with walking
  • Neurologic: headaches (migrainous vertigo), weakness, numbness, seizures (vascular, tumours, MS)
  • Psychiatric: anxiety, hyperventilation, hallucinations (not usually vertigo)
  • Cardiac: palpitations
  • Autonomic: dysautonomia leading to postural hypotension
  • Degenerative: presbystasis
  • Metabolic

Clues to Diagnosis if Vertigo (Duration)

  • Seconds (5–90 secs): BPPV
  • Minutes (2–20 mins): Vascular (usually with other symptoms); Non-vascular causes also possible
  • Hours (20 mins–24 hrs): Ménière’s disease (often 4–8 hrs), Migraine, Acoustic neuroma (e.g., infarction of nerve). Tip: telephone positive sign.
  • Days: Strongly suspect Vestibulo-Neuro-Labyrinthitis (VNL).

Note: Perilymphatic fistula can present with any of the above, usually associated with hearing loss.

Examination of the Dizzy Patient

  • General Examination: pulse, blood pressure, temperature
  • ENT, Head & Neck
  • Neurotologic/Balance tests: Fistula test, Eye movements, Gait, Romberg, Unterberger, Hallpike, and other coordination tests

Eyes

Smooth Pursuit

  • Allows clear continuous vision of moving objects
  • Test: target ~1 m from patient
  • If abnormal: consider brainstem or cerebellar pathology; medications (benzodiazepines, anticonvulsants, lithium)

Saccadic Eye Movements

  • Test: two objects 1 m away, ~15° apart
  • Slowing: internuclear ophthalmoplegia (brainstem, MS)
  • Inaccurate: cerebellar
  • Difficulty initiating: Parkinson’s

Nystagmus

  • Direction = fast phase; note plane
  • Types: spontaneous (primary gaze or <30° from midline; remember endpoint nystagmus), evoked (head shake, positioning)
  • Vestibular is typically direction-fixed (vs central)
  • Side of vestibular lesion:
    • Acute hypofunction (e.g., cut vestibular nerve): fast phase contralateral
    • Chronic hypofunction: fast phase contralateral
    • Acute irritative lesion (VNL): fast phase ipsilateral

Snellen’s Oscillopsia

  • Sensitive test for vestibular lesion
  • Read Snellen’s chart with head still, then with ~60° head rotation (1–2 cycles/sec)
  • Normal: degrade by ~1 line; unilateral loss: 2–4 lines; bilateral loss: 5–6 lines
  • Useful for monitoring ototoxic medications

Gait and Posture

  • Is gait relatively normal?
  • Does the patient require assistance to walk/stand?
  • Wide-based gait suggests cerebellar disorder; shuffling suggests Parkinson’s
  • Vearing into wall can indicate vestibular/cerebellar pathology

Romberg Test

Sharpened (tandem) Romberg tests dorsal columns and vestibular function.

Unterberger (Fukuda) Test

Marching in place, eyes closed, arms extended. Positive if >45° turn in 50 steps; good vestibular test.

Hallpike Test

Test for BPPV. Positive if nystagmus with/without subjective vertigo.

Investigations

  • Audiogram (pure tone and speech discrimination)
  • Vestibular Function Tests (VFTs):
    • Electronystagmography (ENG)/Video-oculography
    • Rotational chair
    • Posturography
    • Electrocochleography (ECoG) if suspect Ménière’s disease
  • Imaging (if suspect central lesion, atypical features, or asymmetry on tests):
    • MRI/MRA with gadolinium for soft tissue lesions
    • CT petrous temporal bones for bony pathology
  • Blood tests (rarely)
  • Transcranial Doppler: measures blood flow velocity; stenosis increases velocity to maintain flow

Dizziness – Summary (VDLMOP)

Vertigo
Dysequilibrium
Light-headedness
Multisensory Dizziness
Migraine Variant
Ocular Dizziness
Oscillopsia
Psychological Dizziness
Physiologic Dizziness

Revised: 26-02-2003.

Disclaimer

Please note: The above is intended as a general guideline only for Dr. Becvarovski’s patients.

This material should not be used for purposes of diagnosis or treatment without consulting a physician.

Each patient is an individual and should be treated accordingly.

Please contact our rooms if you are concerned or require any further information.

Copyright © 2001. Dr Zoran Becvarovski. All rights reserved.

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