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

1. External auditory canal: vesicles (Ramsay-hunt syndrome), cerumen, cholesteatoma
2. Tympanic membrane: signs of otitis media
3. Hearing: unilateral hearing loss in labyrinthitis, cerumen impaction, meniere’s disease or acoustic neuroma

Neurologic Examination

1. Cranial nerves
2. Cerebellar signs
3. 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
4. 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.

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:

1. Vital signs
2. Cardiovascular examination