HISTORY
Mnemonic: 4D-3E-2Fg-2H
1. Define “Dizziness”:
- Room is spinning/rocking/somersaulting – Vertigo
- Feel like “going to faint” – Near-syncope
- “Going to fall” or “Unsteady on feet” – Disequilibrium
- Feel like they’ve or are “left their body” or “floating/swimming” – Psychophysiologic dizziness
2. Duration of each episode:
- Seconds: BPPV
- Minutes: TIA or Vertebro-basilar insufficiency
- Hours: Meniere’s disease and Migraines
- Continuous for days: Labyrinthitis, Vestibular neuronitis
3. Diplopia, Dysarthria, Dysphagia, Gait abnormalities or orther focal neurologic complaints – Central cause of vertigo
4. Dysrhythmia symptoms – Chest pain, Shortness of breath or Palpitations
5. Exacerbation:
- With head turning, lying down, or rolling over in bed – vertigo
- Change in head position – BPPV
- Loud sounds – “Tulio phenomenon” (Perilymph fistula or Meniere’s disease)
- With standing from sitting/reclining position – orthostatic hypotension
- Walking or standing compared with sitting or lying – disequilibrium
- Stress – psychogenic vertigo
6. Eyes:
- Vertigo that decreases with visual fixation (more with eyes closed) – vestibular (peripheral) origin
- Vertigo that doesn’t lessen with visual fixation (same with eyes open or closed) – central origin
7. Ears:
- Hearing loss: Cerumen impaction, Otitis media, Cerebello-pontine angle tumors
- Tinnitus: Meniere’s disease, Acoustic neuroma, Medication toxicity
6. Febrile viral illness: Recent viral illness – Labyrinthitis or Vestibular neuronitis
7. Food association: Caffeine and lactate may precipitate panic attacks
8. Head trauma in past: BPPV
9. Headache: Migraine or Vertebro-basilar insufficiency
Examination
Eyes for Nystagmus
Vestibular origin:
- Fast component – beats towards the side of lesion
- Inhibited by visual fixation
- Direction of nystagmus doesn’t change with the direction of gaze
- Nystagmus is fatiguable
Central origin:
- Nystagmus is not inhibited by visual fixation
- Nystagmus changes direction with the change in direction of gaze
- Nystagmus is not fatiguable
Ears
- External auditory canal: vesicles (Ramsay-hunt syndrome), cerumen, cholesteatoma
- Tympanic membrane: signs of otitis media
- Hearing: unilateral hearing loss in labyrinthitis, cerumen impaction, meniere’s disease or acoustic neuroma
Neurologic Examination
- Cranial nerves
- Cerebellar signs
- Romberg’s sign:
- Sensory ataxia: Patient loses balance when eyes are closed (removal of visual compensation)
- Cerebellar ataxia: Patient loses balance on standing regardless of eyes being open or closed
- Gait
Clinical Tests
1. Orthostatic hypotension:ย fall in systolic blood pressure of at least 15โ20mmHg within 2 minutes of standing upright.
3. Head thrust/impulse test:ย The patientโs head is quickly rotated about 15ยฐ to the side while the patient fixates on the examinerโs nose. With unilateral peripheral vestibular loss (like labyrinthitis or vestibular neuritis), the eyes cannot maintain focus, and a saccade (quick rotation of the eyes from one fixation point to another) will occur bringing the eyes back to the examinerโs nose.
4. Hennebert’s test: Reproduction of symptoms on pneumatic otoscopy
- True positive – perilymphatic fistula
- False positive – meniere’s disease and otosyphilis
Other examinations must not be missed:
- Vital signs
- Cardiovascular examination
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