ear, nose, and throat disorders
Dizziness and Vertigo
Evaluation of Dizziness and Vertigo
History of present illnessshould cover the sensations felt; an open-ended question is best (eg, “Different people use the word ‘dizziness’ differently. Can you please describe as thoroughly as you can what you feel?”). Brief, specific questioning as to whether the feeling is faintness, light-headedness, loss of balance, or vertiginous may bring some clarity, but persistent efforts to categorize a patient’s sensations are unnecessary. Other elements are more valuable and clear-cut: Severity of initial episode Severity and characteristics of subsequent episodes Symptoms continuous or episodic If episodic, frequency and duration Triggers and relievers (ie, triggered by head/body position change) Associated aural symptoms (eg, hearing loss, ear fullness, tinnitus) Severity and related disability Is the patient having a single, sudden, acute event, or has dizziness been chronic and recurrent? Was the first episode the most severe (vestibular crisis)? How long do episodes last, and what seems to trigger and worsen them? The patient should be asked specifically about movement of the head, arising, being in anxious or stressful situations, and menses. Important associated symptoms include headache, hearing loss, tinnitus, nausea and vomiting, impaired vision, focal weakness, and difficulty walking. The severity of impact on the patient’s life should be estimated: Has the patient fallen? Is the patient reluctant to drive or leave the house? Has the patient missed work days? Review of systemsshould seek symptoms of causative disorders, including symptoms of upper respiratory infection (inner ear disorders); chest pain, palpitations, or both (heart disease); dyspnea (lung disease); dark stools (anemia caused by gastrointestinal blood loss); and weight change or heat or cold intolerance (thyroid disease). Past medical historyshould note presence of recent head trauma (usually obvious by history), migraine, diabetes, heart or lung disease, and drug and alcohol abuse. In addition to identifying all current drugs, drug history should assess recent changes in drugs, doses, or both. Examination begins with a review of vital signs, including presence of fever, rapid or irregular pulse, and supine and standing blood pressure, noting any drop in blood pressure on standing up ( Orthostatic Hypotension ) and whether standing provokes symptoms. If standing does provoke symptoms, postural symptoms should be distinguished from those triggered by head movement by returning the patient supine until symptoms dissipate and then rotating the head. The otologic and neurologic examinations are fundamental. Specifically, with the patient supine, the eyes are checked for presence, direction, and duration of spontaneous Nystagmus . Direction and duration of nystagmus and development of vertigo are noted. A gross Physical examination is done, the ear canal is inspected for discharge and foreign body, and the tympanic membrane is checked for signs of infection or perforation. Cerebellar function is tested by assessing gait and doing a finger-nose test and the Romberg test (see How to Assess Sensation ). The The following findings are of particular concern: Head or neck pain Ataxia Loss of consciousness Focal neurologic deficit Severe, continuous symptoms for > 1 hour Traditionally, differential diagnosis has been based on the exact nature of the chief complaint (ie, distinguishing dizziness from light-headedness from vertigo). However, the inconsistency of patients’ descriptions and the poor specificity of symptoms make this unreliable. A better approach places more weight on the onset and timing of symptoms, the triggers, and associated symptoms and findings, particularly otologic and neurologic ones. Some constellations of findings are highly suggestive (see table), particularly those that help differentiate peripheral from central vestibular disorders. Peripheral: Ear symptoms (eg, tinnitus, fullness, hearing loss) usually indicate a peripheral disorder. They are typically associated with vertigo and not generalized dizziness (unless caused by uncompensated peripheral vestibular weakness). Symptoms are usually paroxysmal, severe, and episodic; continuous dizziness is rarely due to peripheral vertigo. Loss of consciousness is not associated with dizziness due to peripheral vestibular pathology. Central: Ear symptoms are rarely present, but gait/balance disturbance is common. Nystagmus is not inhibited by visual fixation. Patients with a sudden, ongoing attack should have pulse oximetry and fingerstick glucose test. Women should have a pregnancy test. Most clinicians also do an ECG. Other tests are done based on findings (see table), but generally gadolinium-enhanced MRI is indicated for patients with acute symptoms who have headache, neurologic abnormalities, or any other findings suggestive of a central nervous system etiology. Patients with chronic symptoms of central vestibular pathology should have gadolinium-enhanced MRI to look for evidence of Overview of Stroke , Patients for whom results of bedside tests of hearing and vestibular function are abnormal or equivocal should undergo formal testing with audiometry and electronystagmography. ECG, Holter monitoring for heart rhythm abnormalities, echocardiography, and exercise stress testing may be done to evaluate heart function. Laboratory tests are rarely helpful, except for patients with chronic vertigo and bilateral hearing loss, for whom syphilis serology is indicated. 