Clerking dizziness

History

Clerking dizziness should involve a detailed history with regards to characterising the current episode. The examination should include otoscopy, CNS examination, and relevant specific tests.

In clerking the current episode, the following approach should be taken:

  • Differentiate between dizziness and vertigoVertigo is a spinning or rotatory sensation of the patient or his or her surroundings, and is often in keeping with a vestibular event.

    Dizziness or unsteadiness is a more generalised term and may not indicate vestibular pathology.

  • Determine how the episodes began:
    • a preceding upper respiratory infection (labyrinthitis); 
    • a history of sea, air, or train travel prior to the onset of symptoms and with symptoms occurring on disembarking (mal de debarquement (MDD) syndrome);
    • a history of trauma or barotraumas (perilymphatic fistula).
  • Determine whether the vertigo is better with the eyes open or closed
    • Vertigo with a vestibular component is more likely to get better with visual fixation (eyes closed)
    • Vertigo with a central component is not usually better with visual fixation.
  • Determine the duration of the vertigo
    • Vertigo lasting seconds: benign positional paroxysmal vertigo (BPPV), semicircular canal dehiscence, perilymphatic fistula.
    • Vertigo lasting minutes to hours is suggestive of migraine, Meniere’s disease, or cardiovascular disease such as a transient ischaemic attack.
    • Vertigo lasting hours-to-days is suggestive of labyrinthitis, vestibular neuritis, central pathology such as multiple sclerosis or a stroke, or an anxiety disorder.
  • Check for positional triggers
    • Vertigo associated with BPPV  and uncompensated unilateral vestibular loss occur on head movement
    • Dizziness on getting up quickly may be associated with presyncope and orthostatic hypotension (from antihypertensive medication use, vertebrobasilar insufficiency, cardiac arrhythmia or cardiac failure).
    • Dizziness on standing upright for prolonged periods, swimming, or running may be seen in autonomic dysregulation.
  • Ask about the presence of other otological symptoms
    • Hearing loss and tinnitus (Meniere’s disease)
    • Sudden hearing loss and/or tinnitus with acute vertigo lasting hours, and nausea and vomiting (Labyrinthitis)
    • Recurrent attacks of disabling vertigo, with no associated hearing loss or tinnitus (Vestibular neuritis)
    • Episodes of vertigo associated with loud sound and/or altered middle-ear pressure, hyperacusis to bone-conducted sounds, and a conductive hearing loss (Superior semi-circular canal dehiscence)
    • Unilateral hearing loss, and imbalance (posterior fossa tumours)
    • Acute onset of dizziness +/- fever, irritability, and otalgia (bacterial otitis media and labyrinthitis).
    • A malodorous ear discharge and hearing loss with or without tinnitus (cholesteatoma)
    • Associated hearing loss (in systemic lupus erythematosus or multiple sclerosis)
    • Exposure to ototoxic drugs or medications.
  • Ask about other more general symptoms associated with the vertigo
    • Associated chest pain, exertional syncope, and dyspnoea may be related to a cardiovascular aetiology.
    • Vestibular migraine may be associated with aura, visual disturbance, photophobia, or phonophobia, with or without headaches.
    • Nausea is often associated with peripheral vestibular disorders.
    • Neurological symptoms such as gait disturbance, limb weakness, or dysarthria may indicate cerebellar pathology.
    • Episodic vertigo lasting 1 to 15 minutes, with diplopia, dysarthria, ataxia, drop attack, and clumsiness of the extremities (Vertebrobasilar insufficiency).
    • Ataxia, urinary incontinence, and cognitive dysfunction (normal pressure hydrocephalus).
    • Patients with benign intracranial hypertension are often obesity, clumsiness, imbalance, and dizziness, headache and transient poor vision +/- bilateral 6th nerve palsy or tinnitus (benign intracranial hypertension).
    • Photophobia, ocular discomfort, ocular redness, fluctuating sensorineural hearing loss, and imbalance or vertigo (Cogan’s syndrome).
    • Serous otitis media, chronic otitis media, sensorineural hearing loss, and facial nerve palsy (Wegener’s granulomatosis).
    • Hearing impairment, tinnitus, recurrent genital and oral ulceration and uveitis (Behcet’s disease).
    • History of outdoor exposure in areas with high tick populations with rash, headache, neck pain and stiffness, sore throat, otalgia, tinnitus, facial and motor dysfunction, hearing loss, and facial palsy (Lyme disease).
    • Symptoms of secondary and neurosyphilis.
    • Vertigo with sensorineural hearing loss preceded by herpetic skin lesions (reactivation of latent HSV-1 infection).
  • Ask about psychiatric symptoms
    • Panic disorder with agoraphobia, personality disorders, or generalised anxiety.
    • Symptoms of excessive anxiety or fear (psychogenic dizziness).
    • Phobic postural vertigo is characterised by dizziness on standing and walking, despite normal clinical balance tests.
    • Avoidance behaviour to specific stimuli.
  • History of previous trauma or surgery
    • Dizziness may be a complication of middle-ear surgery.
    • Vertigo and balance disturbance may also occur after cochlear implantation.
    • A perilymphatic fistula may occur after stapes surgery or head trauma or in divers. It is characterised by paroxysmal vertigo, imbalance, and a sensorineural hearing loss with or without tinnitus.
    • Post-traumatic vertigo generally occurs as a result of blunt head trauma such as a fall, an assault, or a motor vehicle accident. Patients may complain of vertigo, disequilibrium, tinnitus, pressure, headache, and diplopia.

    History of other medical illnesses

    • Assess for risk factors for stroke, such as hypertension, hyperlipidaemia, diabetes mellitus, or heart disease.
    • Diabetes mellitus (dizziness from hypoglycaemia).
    • Hypothyroidism and SLE.
    • Multiple sclerosis (nystagmus, ataxia, and cranial nerve palsies).
    • History of migraine.

    Family history of illness

    • Family history of migraine.
    • Family history of hereditary ataxias. Most commonly, Friedreich’s ataxia (ataxia, vertigo, nausea and vomiting, dysarthria, and nystagmus before the age of 20 years).

    Social history

    • Smoking
    • History of associated acute intoxication with alcohol.

    Medication and drug history

    • History of use of aminoglycoside antibiotics such as gentamicin and neomycin (particularly if these have been administered concomitantly with loop diuretics or aspirin), chemotherapeutic agents (e.g., cisplatin), antihypertensives, anaesthetics, or anti-arrhythmics.

    Physical examination

  • General examination may reveal evidence of other conditions (e.g., oral ulcers with Behcet’s disease; joint disease with rheumatoid arthritis; evidence of multi-system involvement with systemic lupus erythematosus; and rashes with Lyme disease, HIV, or syphilis).
  • CNS Examination

    Ear examination

    • The tympanic membrane in acute otitis media is erythematous, opaque, and bulging.
    • In cholesteatoma, otoscopy reveals crust or keratin in the attic (upper part of the middle ear), pars flaccida, or pars tensa (usually posterior superior aspect), with or without perforation of the tympanic membrane. 
    • There may be evidence of fluid or blood in the middle ear and/or cerebrospinal fluid (CSF) otorrhoea if the dizziness is related to trauma.
    • Signs of serous otitis media or chronic otitis media in Wegener’s granulomatosis.

    The fistula test

    • Performed by applying pressure on the tragus to occlude the ear or by pneumatic otoscopy (exerting pressure on each ear canal with a rubber bulb attached to an auriscope), thereby putting pressure on the middle ear.
    • A positive result of induced dizziness and nystagmus occurs with superior semi-circular canal dehiscence, post-surgical dizziness, or perilymphatic fistula.
    • Fistula test may be positive in people with cholesteatoma.

    Eye examination

    • The presence of nystagmus may indicate peripheral or central pathology.
    • A central vestibular lesion produces vertical, bidirectional, or pure rotatory nystagmus. Abnormal saccades and smooth pursuit may also indicate central pathology.
    • Observation of the eyes may lead to suspicion for other ophthalmological conditions, such as interstitial keratitis in Cogan’s syndrome or uveitis in Behcet’s disease.

    Observation of eye movements

    • Ophthalmoplegia with palsies of cranial nerves III, IV, or VI may occur with multiple sclerosis or with an intracranial lesion.
    • Neurological signs such as diplopia, disconjugate gaze, Horner’s syndrome, and gait ataxia are in keeping with a central lesion.

    Examination of dynamic visual acuity

    • This tests the vestibulo-ocular reflex by observing the effect of head rotation on visual acuity (e.g., by reading the letters on a Snellen chart). [42]
    • Abnormal results indicate a bilateral vestibular failure.

    Clinical balance tests

    The head impulse test

    • Particularly useful to differentiate between acute vestibular neuritis and cerebellar stroke in patients with acute vertigo.
    • The examiner turns the patient’s head as rapidly as possible 15 degrees to one side and observes the patient’s ability to keep fixating on a distant target. With a peripheral vestibular lesion, a saccade occurs as the vestibulo-ocular reflex fails, the patient cannot keep focusing on the target, and a catch-up movement occurs. After a cerebellar stroke, no catch-up saccade occurs. The head-impulse test is negative (no saccadic adjustment of the eyes on sudden head twisting) in people with cerebellar stroke, ruling out acute vestibular neuritis or labyrinthitis.

    The Dix-Hallpike test

    • This is useful in patients with a history suggestive of BPPV.
    • The test is performed by sitting the patient upright on a bed; for the right side, the examiner stands on the patient’s right side, rotates the patient’s head 45° to the right, and then moves the patient, whose eyes are open, to the supine right-ear down position, and then extends the patient’s neck slightly so that the chin points slightly upwards. Patient’s symptoms are noted and any nystagmus is observed. This manoeuvre is associated with strong subjective symptoms, and the patient may cry out.

Supine roll test

    • If the Dix-Hallpike test is negative in a patient who has a history suggestive of BPPV, a supine roll test should be performed. This test is performed by positioning the patient supine with the head in the neutral position, then quickly rotating the head 90° to one side while the clinician observes the patient’s eyes for nystagmus. The head is returned to the face up position, allowing all dizziness and nystagmus to subside; the head is then turned rapidly to the opposite side.

    Examination of the other cranial nerves

    • Other cranial nerve palsies such as facial weakness or numbness may occur with cerebellopontine angle tumours.
    • Tongue weakness with limb weakness may be a feature of a cerebral stroke.
    • Facial nerve palsy may occur with Wegener’s granulomatosis (granulomatosis with polyangiitis).

    Neurological examination

    • Examination of cerebellar function is usually tested with the finger-to-nose test and rapid alternating hand movements. This may be abnormal in cerebellar lesions.
    • Gait should be checked for any disturbance, along with examination for limb weakness or dysarthria. These may indicate a neurological pathology such as cerebellar infarction or other cerebellar pathology.
    • Wallenberg’s syndrome (lateral medullary infarction caused by occlusion of the ipsilateral vertebral artery that supplies the posterior inferior cerebellar artery) causes prolonged vertigo, abnormal eye movements, ipsilateral Horner’s syndrome, ipsilateral limb ataxia, and loss of pain and temperature sensation of the ipsilateral face and contralateral trunk.
    • Patients with Freidreich’s ataxia demonstrate cerebellar ataxia, sensory neuropathy with areflexia, dysarthria, and optic atrophy. The rare familial episodic ataxias may demonstrate ataxia, dysarthria, and nystagmus.
    • Various neurological signs may be present in people with multiple sclerosis (e.g., altered gait, weakness, nystagmus, cranial nerve palsies).
    • Signs of peripheral neuropathy may occur in patients with diabetes mellitus (e.g., numbness and presence of painless injuries).

    Romberg and Unterberger (Fukuda) tests

    • Provides information about the patient’s balance with the eyes closed. The Romberg test involves asking the patient to attempt to maintain a standing position with the feet together, eyes closed, and arms outstretched. The Unterberg test involves asking the patient to perform stationary stepping with eyes closed for up to 1 minute. A tendency to veer towards the affected side occurs after a unilateral vestibular loss.
    • These are non-specific tests that can be abnormal in peripheral or central lesions.
    • Patients with cerebellar infarction usually cannot stand without support, even with the eyes open, whereas a patient with acute vestibular neuritis or labyrinthitis can.
    • Bizarre changes (e.g., ‘wooden soldier’ or ‘scissor gait’) may occur in psychogenic lesions.
  • Cardiovascular system examination

    • It is important to check for an irregular pulse or carotid bruits, especially in older patients or those with risk factors such as hypertension.
    • Lying and standing BP should be checked, for possible orthostatic hypotension. 

    Investigations

    The diagnosis of dizziness is usually made on the basis of the history and examination only. Investigations may not be necessary. Magnetic resonance imaging (MRI) of the brain and internal auditory meatus should be carried out if there is concern that there may be central pathology. Vestibular function tests are indicated in some cases. Tests of cardiovascular function may be necessary if a cardiovascular cause is suspected.