Dizziness and Vertigo
Marina Boruk
Neil M. Sperling
Dizziness and vertigo are frequent symptoms encountered in all fields of medicine. The task of managing a patient with dizziness can be exasperating. It is essential to address the patient’s problem in a systematic way to determine the likely cause and to direct therapy. This begins with a thorough history followed by a focused physical examination and evaluation.
True vertigo can be defined as the sensation of motion in a stationary environment. Dizziness can describe true vertigo, but many patients use the term dizzy to explain feelings of light-headedness, nausea, unsteadiness, nervousness, or feeling overheated. A thorough history helps differentiate these varied symptoms and direct the clinician toward the differential diagnosis. A practical paradigm to aid in deciphering the causes of vertigo and dizziness divides the causes into three main categories: systemic, peripheral (labyrinthine or vestibular), and central (central nervous system). Differentiating peripheral from central causes of dizziness is a frequent role of the otolaryngologist.
HISTORY
An accurate history is the crucial factor in the care of a patient who reports dizziness. Start by having the patient describe the dizziness in as much detail as possible. It is imperative from the outset to differentiate true vertigo from other types of dizziness. Presyncope, or light-headedness, may be related to a cardiac, vascular, or metabolic disease. Dysequilibrium, feeling out of balance, is a nonvertiginous symptom that may be attributable to vestibular or central causes. Ascertaining that a patient is not experiencing true vertigo directs the clinician to consider systemic causes.
Onset of Symptoms
If the patient’s symptoms are consistent with true vertigo, a detailed, accurate history should lead directly to a presumptive diagnosis. It is now a matter of framing the vertigo into a primarily peripheral (vestibular, labyrinthine) or central (i.e., central nervous system, CNS) phenomenon (Table 11-1). Begin by investigating the onset and duration of symptoms. Vertigo of recent or abrupt onset generally describes a peripheral mechanism (benign positional vertigo, vestibular neuronitis, Meniere’s disease), or cerebrovascular event. Vertigo of a more insidious onset points primarily toward a central cause (multiple sclerosis, ataxic disorder, seizure disorder, tumor, or CNS malformation).
Duration of Symptoms
Duration of symptoms further delineates the cause. Peripheral causes of vertigo usually are intermittent or of shorter duration. Central causes tend to be continuous or of longer duration. Peripheral causes of vertigo generally fall into four groups based on duration of symptoms (Table 11-1).
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Frequency of Symptoms
Further information gathering clarifies the diagnosis. Discuss the frequency of the attacks and the latent period between attacks. Vertiginous episodes that occur in clusters with asymptomatic latent periods describe a peripheral cause. Regular occurrence of episodes with continued unsteadiness between attacks appears more often with a central cause. It is important to ask whether there is a positional component to the vertigo. If the vertigo is associated with changes in position, a peripheral cause should be sought (benign paroxysmal positional vertigo). A viral illness or upper respiratory tract infection preceding the onset of the symptoms is common in peripheral causes of vertigo (Meniere’s disease, vestibular neuronitis).
Otologic History
Any ear or hearing symptoms associated with vertigo suggest a peripheral cause of symptoms. The vestibular apparatus is contained within the inner ear, so it follows that any condition that affects one system may affect the other. Question the patient regarding tinnitus, otorrhea, otalgia, deafness (transient), or changes or worsening of hearing associated with vertigo. It is important to explore the patient’s history for any chronic ear infections, operations on the ear, or chronic changes in hearing that may coexist with or have occurred before the onset of vertigo. Questions also should be directed at other potential causes of labyrinthine dysfunction, such as exposure to syphilis (even if the patient has been treated) or to ototoxic medications (aminoglycosides, loop diuretics). Head or ear trauma
can lead to vertigo as the result of a labyrinthine fracture, perilymphatic fistula, or labyrinthine concussion.
can lead to vertigo as the result of a labyrinthine fracture, perilymphatic fistula, or labyrinthine concussion.
Central Nervous System Disease
An array of symptoms commonly encountered with vertigo suggests a central pathologic condition. The history should include information about any prior visual disturbances, headaches or migraine, or seizures, and any family history of these disorders or any other neural dysfunction. Ataxia often is associated with vertigo of central origin. Nausea and vomiting are intimately related to vertigo of central and peripheral etiologies, because the emesis region of the brain is adjacent to the vestibular centers. An increase in intracranial pressure or mass effect in this region (the cerebellopontine angle) can cause simultaneous symptoms.
PHYSICAL EXAMINATION
A physical examination narrows the differential diagnosis and reaffirms the information gleaned from the history. An examination of the ears, related neurologic structures, and cranial nerves is indicated for patients with dizziness consistent with vestibular dysfunction. A history that directs the differential diagnosis toward the systemic causes of dizziness necessitates a full medical examination.
Examination of the ears should include inspection, palpation, otoscopy with insufflation, and tuning fork testing. Otoscopy helps determine the health of the tympanic membrane and middle ear and gives evidence of past or active infection. Insufflation of the tympanic membrane of a patient with vertigo is referred to as a fistula test. If the patient reports increasing symptoms and nystagmus is seen while positive pressure is applied in the external canal, the patient has a positive fistula test result, which suggests leakage of labyrinthine fluid. Tuning fork testing may uncover hearing asymmetry, but audiologic evaluation is recommended if vestibular disease is suspected.
Nystagmus is rhythmically beating eye movement in which a slow phase alternates with a fast phase in the opposite direction. Nystagmus is named for the direction of the fast component. It generally reflects an imbalance of the vestibular-visual-somatosensory axis and may be caused by asymmetry of bilateral vestibular inputs. Patients experiencing acute vertigo have violent, rapid nystagmus. Vertical, pure rotatory, and bidirectional midline nystagmus (eyes beat minimally to both sides equally when staring straight ahead) are almost always indicative of central abnormality. Horizonto-rotary nystagmus is consistent with peripheral pathology. Lateral-gaze nystagmus refers to nystagmus present when a patient is asked to change the gaze toward one side. It usually signifies peripheral abnormality. Endpoint lateral-gaze nystagmus can be physiologically normal, so it is important when testing for nystagmus to limit eye movement to 30 degrees on either side of the midline.
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