Dizziness : History and Examination

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: fall in systolic blood pressure of at least 15–20mmHg within 2 minutes of standing upright.

2. Hallpike test

3. Head thrust/impulse test: The patient’s head is quickly rotated about 15° to the side while the patient fixates on the examiner’s 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 examiner’s nose.