Evaluation of the Dizzy Patient

This material is intended for clinicians (in outpatient or hospital settings, but not emergency department).

See also: dizziness in the emergency department

Timothy C. Hain, MD

Page last modified: May 1, 2022

THE DIZZINESS PROBLEM

  1. Dizziness is the primary complaint in 2.5% all primary care visits = 8 million/year visits (Sloan). Practically, there are far more patients with dizziness/ataxia than there are clinic openings with doctors with an interest in caring for them.
  2. There are substantial otologic (40-50%), neurologic (10-30%), general medical (10-30%), and psychiatric/undiagnosed causes of vertigo (15-50%).
  3. Dizziness presents a significant sorting problem. Because of the diverse causes, patients prefer a "symptom" oriented setting (i.e. a dizzy clinic) to a "cause" oriented setting (i.e. sequential visits and testing in an ENT, Neurology, Cardiology, or Psychiatry subspecialty setting).

As a general comment, nearly anybody in medicine, whether or not that they have any familiarity with the subject, seem prone, from time to time, to write a paper about dizziness. This is because dizziness is common, and it is easy to find 100 or so patients on whom to pontificate. We ourselves do not think that this subject is so easy, because it involves sorting through an immense number of etiologies, some of which are rather obscure (e.g. cholesteatoma).

SURVEY OF CAUSES OF DIZZINESS:

  1. Otologic causes(about 50% of vertigo in otology settings, e.g. see Nedzelski reference)
    1. Physiology
      1. Canals register head velocity
      2. Otoliths register linear acceleration
      3. Together provide input to two central reflexes, VOR (Vestibulo-Ocular reflex) and VSR (Vestibulo-Spinal Reflex)
    2. Three patterns of Injury
      1. Asymmetrical, unilateral loss (Vertigo and "listing")
      2. Symmetrical bilateral loss (Oscillopsia and ataxia)
      3. Cross-coupling (positional vertigo, pressure sensitivity, Tullio's phenomenon)
    3. Most common types of otologic dizziness
      1. Asymmetrical dysfunction:
        1. Vestibular Neuronitis - monophasic illness without hearing disturbance.
        2. Meniere's disease - episodic hearing disturbance and dizziness
      2. Symmetrical dysfunction
        1. Ototoxins - look like midline cerebellar disease. Diagnosis often has medicolegal implications.
        2. Bilateral forms of unilateral diseases such as vestibular neuritis can cause similar symptoms.
      3. Crosscoupling
        1. Benign Paroxysmal Positional Vertigo (BPPV) - About 20% of all patients, the most important type of vertigo to recognize.
        2. Perilymph fistula and SCD (superior canal dehiscence syndrome)-- rare form of vertigo where internal or external pressure changes or sound induce vertigo (Tullio's phenomenon).
        3. Rarely central vertigo causes cross-coupled caloric or head-shaking nystagmus. In this context it may be called "perverted" nystagmus.
    4. Neurological Dizziness - 10-30% of all vertigo in neurological settings,(Drachman and Hart, 1972; author's material, 1992), about 5% of vertigo everywhere else.
      1. Physiology: Vestibular nucleus in brainstem gets information from eyes, ears, joints. It resolves contradictions/ambiguities (somatosensory integration), and produces output to drive VOR and VSR reflexes. Some somatosensory integration may also occur in the spinal cord. Repair/readjustment of these reflexes is an ongoing process. Much repair is mediated by the cerebellum, but repair processes also include local recovery of neuronal circuitry and cognitive adjustments. Cerebellar injuries are particularly bad because CNS may be unable to repair an injury, or repair process gone amok may contribute to disability.
      2. General features: Central vertigo is slower to recover than otologic causes of vertigo. It is usually relatively unaffected by sensory input. There may be obvious mismatches between nystagmus and vegetative symptoms (i.e. headaches, nausea, fatigue).
      3. Most common types: Sites of injury include the vestibular nucleus and the cerebellum.
        1. Vertebrobasilar insufficiency and stroke - most common
        2. Multisensory Disequilibrium -- important cause of ataxia in elderly.
        3. Migraine - about 10% of central vertigo
        4. Cervical "Vertigo" - very uncommon.
        5. Low CSF pressure syndrome (post-LP, CSF leak) -- can resemble symptoms of Meniere's disease because tinnitus is common.
    5. General Medical Problems - only about 5% of specialty clinics, but 30% of ER diagnoses (ER: Madlon-Kay)
      1. Blood Pressure/Arrhythmia (syncope, orthostatic hypotension, cardiac arrhythmia and angina with prominent blood pressure effects)
      2. Hypoglycemia (diabetics, people who don't eat regularly)
      3. Medication (mainly antihypertensives and vasodilators)
      4. Infection (ER mainly, gastroenteritis, pneumonia, UTI, middle ear). Covid-19 is not a large cause of dizziness other than very sick people.
      5. B12 deficiency -- About 10% of 80 year olds have B12 deficiency. A cause of ataxia.
    6. Unlocalized causes of dizziness 35-50% of vertigo (Madlon-Kay, Nedzelski, Drachman-Hart, Kroenke).
      1. Psychiatric -- in the dizzy patient, the diagnosis of psychiatric disease is often made by otolaryngologists. Authors view is that while psychogenic dizziness clearly does exist, in many cases it is just a variant of unknown. The frequency of this diagnosis varies very substantially between authors (15% -- for "dizzy" doctors, 50% is typical for ER settings, for subspecialty clinics that do not consider entire spectrum of diagnoses (i.e. Nedzelski et al) and in family practice settings (e.g. Kroenke et al)). Anxiety and Panic are most common recognizable entities. School avoidance is seen in adolescents. Somatization syndrome, anxiety and malingering occurs in young adults and middle aged. Depression equivalent and anxiety is more common in elders.
      2. Hyperventilation -- this diagnosis also varies dramatically between series. Authors view is also that it is usually just a variant of unknown. Other authors view it as a variant of anxiety.
      3. Unknown -- Again this diagnosis varies substantially between series. It is the single most common diagnosis in the ER (probably because they only have one shot at making the diagnosis).

    HISTORY OF THE DIZZY PATIENT

    1. History is frequently more important than the examination. For example, one can usually easily spot BPPV through history (about 20% of dizzy patients). This allows you to focus a comprehensive lengthy examination. A questionnaire is very helpful. Wuyts et al (2016) has offered the "SO STONED" mnemonic -- Symptoms, Often, Since, Trigger, Otology, Neurology, Evolution, Duration. This seems a little strained.
      1. Define: patient's dizziness: Vertigo, Impulsion, lightheaded, oscillopsia, ataxia, confusion.
      2. Timing:
        1. Onset
        2. Frequency
        3. Duration: (BPPV-seconds, TIA-minutes, Menieres-hours, Vestibular Neuronitis-Days, Ototoxins-years). See Hain, 1997 reference for more detail about timing categories.
        4. Evolution (getting better, worse, stable)
      3. Associations and triggers: head motion or change in head position, hearing disturbance, headache, cognitive symptoms, relation to stress.
      4. Review of systems: especially vascular risk factors and ear surgery.
      5. Family History: Similar disorder ? Migraine
      6. Medication History: present and past exposures to ototoxins, antihypertensives.
      7. Previous studies

    Examination of the Dizzy Patient

    1. General Medical Examination -- rarely contributory but important because of the life-threatening nature of cardiac disorders.
      1. Blood pressure - Orthostatic changes in blood pressure or pulse, Hypertensive ?
      2. Cardiac - arrhythmia, murmur, bruit ? (arrhythmia's are most common source of dizziness in persons with cardiac disorders)
    2. Ophthalmological examination
      1. Ophthalmoscopic - Papilledema ? Hypertensive changes ? A good point to also do the two "ophthalmoscope tests", see item #5
      2. Oculomotor examination
        1. Nystagmus (saccadic, vestibular, pendular, congenital, alternating)
        2. Rebound nystagmus
        3. Saccades, pursuit, vergence, gaze
        4. Optokinetic nystagmus -- rarely useful.
    3. Otologic Examination
      1. Hearing -- often helpful. A very simple screen is to simply check high frequencies with rubbed fingers. Use yourself as the control.
      2. Inspect tympanic membranes -- rarely helpful -- may see wax, perforation, scarring.
      3. Be prepared to remove wax -- this is a good idea as it helps your patients and allows you to see the ear drum.
    4. Neurological Examination -- rarely productive but should be done for safety
      1. Cranial nerves, especially 7
      2. Motor power and reflexes, pathological reflexes (e.g. Babinski) -- rarely helpful.
      3. Sensory (proprioception) -- almost never productive.
      4. Cerebellar signs - finger to nose, tandem gait. Rarely helpful, but there are a few cerebellar degenerations that will come in with dizziness.
      5. Gait and Station (Timed Tandem Romberg (TTR), cerebellar ataxia, Parkinsonism, functional)
    5. Vestibular Examination -- generally very helpful in making diagnosis (See Cherchi and Hain, 2010 for a review).
      1. a. Spontaneous nystagmus is most helpful for diagnosing Meniere's disease, Vestibular Neuronitis, central disorders, to rule out Psychiatric.
        1. Frenzel's goggles - Extremely useful. A video system which occludes vision is best.
        2. Ophthalmoscope test for spontaneous - Block vision with one hand, with ophthalmoscope with the other. This is a poor substitute for Frenzel goggles.
      2. Fixation Suppression -- modestly helpful when it is poor, but this is rarely encountered. Pursuit deficiencies in otherwise normal elderly adults make this test useless in persons over the age of 60.
        1. Peripheral vestibular - good suppression unless very strong nystagmus
        2. Central vestibular - suppression varies. If weak nystagmus and no suppression, likely central. This is uncommon as we have a lot more patients with ear disorders than brain disorders.
      3. VOR asymmetry is most helpful for diagnosing vestibular neuritis, acoustics, and to reduce the likelihood of psychiatric disturbance (of course, patients can have BOTH).
        1. Head-shake test - (Hain et al, 1987). Helpful when done properly. About 75% sensitive but suggests the wrong side about 1/4 of the time.
        2. Head-impulse test (Rapid Dolls) - (Halmagyi, 1988; Harvey and Wood, 1996). Can be very helpful in vestibular neuritis.
        3. Vibration of the sternocleidomastoids combined with video frenzels -- sensitivity is about 90% to unilateral vestibular loss.
      4. VOR gain is most helpful for diagnosing ototoxicity and other bilateral vestibulopathies
        1. Dynamic illegible 'E' test or DIE (Longridge, 87). Very helpful. Sensitive but of course can be faked.
        2. Ophthalmoscope test (Zee, 78). Not always positive when DIE is positive. Cannot be faked.
        3. Dolls eyes. This test is rarely positive in patients with no vestibular function at all. Best done in dark.
      5. Special maneuvers, mainly involving evoked nystagmus, are helpful for diagnosing BPPV (20% all vertigo), Fistula, Syncope, Hyperventilation test
        1. Dix-Hallpike - EXTREMELY IMPORTANT. Should do with Frenzels.
        2. Fistula Test or Valsalva test- . Occasionally helpful. Valsalva nystagmus is rare but specific. Fistula test is very insensitive.
        3. Hyperventilation test - 30 seconds, look for nystagmus. Helpful when nystagmus changes direction compared to vibration or head-shaking nystagmus.
        4. Carotid Sinus Compression - for syncope patients. Reluctant to do routinely.
        5. Vertebral artery test -- for persons with neck-position induced vertigo (cervical vertigo). Very insensitive

    FORMULATING YOUR IMPRESSION

    Think of this as a sorting or matching process, not as a decision tree. Diagnoses fall through the sorting sieve. Decision trees are prone to error as a wrong fork may lead one into a blind alley. Regroup if treatment is not successful and back up.

    1. Diagnoses directly based on the examination-- includes general medical.
      1. BPPV - Positive Dix/Hallpike
      2. Fistula or related syndrome such as SCD - Pressure sensitivity or sound sensitivity
      3. Cervical vertigo -- nystagmus elicited by changing position of neck r. e. trunk.
      4. Ototoxicity - Fails dynamic illegible E test and Tandem Romberg test
      5. Cardiac problems - blood pressure/arrhythmia/carotid sinus sensitivity. These conditions have high mortality and are common.
      6. Multisensory - significant deficit in visual/somatosensory function
      7. Hyperventilation - reproduces symptoms, no other exam positives. Be careful here, because acoustics and multiple sclerosis may have substantial HVT sensitivity.
    2. Other peripheral vestibular problems - positives on vestibular tests. Vestibular Neuritis/Labyrinthitis, Meniere's. ENG, audiometry, VEMP, and ECochG tests are often useful in this group.
    3. Neurological problem - central pattern history or exam. Stroke, sensory ataxia, cerebellar ataxia, migraine, central nystagmus. MRI single most useful test. EEG if paroxysmal quality. Medication trials often helpful for migraine/seizure.
    4. Psychiatric problems - normal or inconsistent exam, history. Agoraphobia, panic attacks, depression, malingering. Psychiatric referral is occasionally useful, mainly in anxious. . A trial of benzodiazepines or SSRI medications may be helpful to, although they may also help in non-psychiatric dizziness. An SNRI such as venlafaxine also treats migraine.
    5. Other medical problems -- rarely gastritis causes nausea, etc.
    6. Unknown cause - nonspecific exam/history. This may be a substantial group, especially if you are not very confident about pattern recognition. At this point it may be helpful to regroup and sort patients based on timing (see Hain, 1997 and later editions in reference list).

    References

    1. Cherchi, M. and T. Hain (2010). Provocative Maneuvers for Vestibular Disorders. Vertigo and Imbalance: Clinical Neurophysiology of the Vestibular System. S. Eggers and D. S. Zee, Elsevier.
    2. Drachman, D. A. and C. W. Hart (1972). "An approach to the dizzy patient." Neurology 22(4): 323-334. (Classic article on sorting out dizzy patients)
    3. Hain TC, Fetter M, Zee DS. Am J Otol, 8:36-47, 1987 (Head-shaking Nystagmus )
    4. Hain TC. Approach to the Dizzy patient in Practical Neurology (Ed. J. Biller), 1997. This reference gives more detail about the approach outlined here. This book has undergone many editions, and the most recent version of this chapter is 2016.
    5. Halmagyi GM, Curthoys IS. Arch Neurol 45:737-740, 1988 (Rapid Dolls)
    6. Harvey SA, Wood DJ. The oculocephalic response in the evaluation of the dizzy patient. Laryngoscope 106:6-9, 1996
    7. Herr, R. D., et al. (1989). "A directed approach to the dizzy patient." Ann Emerg Med 18(6): 664-672.
    8. Kroenke, K., et al. (1992). "Causes of persistent dizziness. A prospective study of 100 patients in ambulatory care." Ann Intern Med 117(11): 898-904. (Psychiatric)
    9. Kroenke, K., et al. (2000). "How common are various causes of dizziness? A critical review." South Med J 93(2): 160-167; quiz 168.
    10. Lanska DJ, Goetz CG, Romberg's sign. Development, adoption, and adaptation in the 19th century. Neurology 2000:55:1201-1206
    11. Longridge NS, Mallinson AI. The dynamic illegible E (DIE) test: a simple technique for assessing the ability of the vestibuloocular reflex to overcome vestibular pathology. J Otolaryngol 1987;16:97-103, Acta Otol (Stockh) 103: 273-279, 1987; Otolarygol HNS 1984:92:671-7
    12. Madlon-Kay, D. J. (1985). "Evaluation and outcome of the dizzy patient." J Fam Pract 21(2): 109-113. (ER)
    13. Nedzelski, J. M., et al. (1986). "Diagnoses in a dizziness unit." Journal of Otolaryngology 15(2): 101-104. (Otology setting)
    14. Nelson JR. Neurology 19: 577, 1969 (Neurology setting)
    15. Wuyts F, Rompaey VV, Maes L. "SO STONED": Common sense approach to the evaluation of the dizzy patient. Frontiers in Surgery, May 2016. [This is an open access journal]
    16. Zee DS. Ann Neurol 3: 373, 1978 (Ophthalmoscope test)

    Self-Test questions:

    (True/False)

    1. Most dizziness originates from inner ear disturbances.

    2. In the Dix/Hallpike Maneuver one expects to see a nystagmus which has both vertical and rotatory components

    Answers:

    1. False. Dizziness has numerous causes -- the proportion of cases with medical, otologic, neurologic, psychiatric, and undiagnoseable sources of dizziness depends on your referral base.
    2. True. Classic posterior canal (PC) BPPV is an upbeating and torsional nystagmus.