Vertigo Diagnosis

Past medical history

• Note patient’s past or current medications, history of trauma or exposure to toxins
  • Medications such as aminoglycosides, some diuretics, antidepressants, antipsychotics and alcohol can cause vertigo

• Presence of diabetes and hypertension puts the patient at high risk for cerebrovascular causes of vertigo

Family history

• Patients with Meniere’s disease or migraine may have strong family history

Physical Examination

• Check head and neck, central nervous system and cardiovascular system
• Distinguish central from peripheral causes of vertigo

Head and neck examination

• Check for facial asymmetry that may suggest either peripheral facial nerve involvement or cerebrovascular disease
• Examine the tympanic membrane
  • Presence of vesicles suggest herpes zoster oticus
  • Check for cholesteatoma or chronic suppurative otitis media

• Apply external pressure on the tragus, and if vertigo occurs, this may suggest perilymphatic fistula
  •  Similarly, if vertigo occurs after asking patient to do Valsalva maneuver, this may also be due to perilymphatic fistula

Neurologic examination

• Perform complete neurologic examination to rule out central causes of vertigo especially those that are life-threatening (eg stroke)
• Examine the cranial nerves
  • Check for palsies, sensorineural hearing loss, nystagmus (eg vertical nystagmus due to central cause of vertigo)
  • Observe certain features of nystagmus such as type, intensity, latency, spontaneity, duration, direction, fatigue, suppression by visual fixation and associated changes with eye movements

Cardiovascular examination

• Check for orthostatic changes in blood pressure (BP) (eg decrease in BP ≥20 mmHg) and in pulse rate (eg increase of ≥10 beats per minute)
  • This may suggest autonomic dysfunction or dehydration

Clinical Tests

• May be used to evaluate vestibular function and to differentiate peripheral from central vertigo
• Dix-Hallpike maneuver and supine head roll test should be used with caution in patients with cervical stenosis, severe kyphoscoliosis, limited cervical range of motion, Down syndrome, severe rheumatoid arthritis, cervical radiculopathies, Paget’s disease, ankylosing spondylitis, spinal cord injuries, morbid obesity

Romberg Test

• Assesses peripheral proprioception and vestibular function
• Romberg test is positive when patient can maintain balance while standing with both feet together and both eyes open, but loses balance when eyes are closed
• Examiner should be ready to assist the patient in case he/she loses balance
• In unilateral peripheral disorders, patient will lean or fall to the side of the lesion

Dix-Hallpike Maneuver

• Gold standard test for posterior canal benign paroxysmal vertigo
• Patient initially sits upright; the examiner turns the patient’s head 45° to the side being tested; then, the examiner quickly moves the patient, whose eyes are open, from the seated position to supine right-ear-down position, allowing the neck to hyperextend and the head hangs off the edge of examining table 20° to 30° past the horizontal plane; patient’s eyes are observed for rhythmic oscillation or nystagmus; examiner should note the latency, duration and direction of nystagmus
• A torsional upbeat of horizontal nystagmus is a positive test for benign paroxysmal vertigo

Supine Head Roll Test

• Used in the diagnosis of lateral canal benign paroxysmal vertigo, after a negative Dix-Hallpike maneuver
• Initially, the patient is in supine neutral position; the examiner briskly turns the patient’s head 90° to one side and observes for nystagmus; head is then turned back to neutral position; same procedure is done, this time turning the head to the opposite side

 Head Impulse Test (HIT)

• Sensitive and specific test to detect unilateral hypofunction of peripheral vestibular system
• May differentiate between cerebellar infarction and acute vestibular neuronitis; HIT is abnormal in the latter
• The examiner holds the head of the patient firmly and turns it rapidly with care to 1 side past the midline, then to the other side; patient should be able to fix his/her gaze on a point behind the examiner; when the patient’s head is turned to the side of the lesion, the eyes will move with the head such that the gaze is no longer on target; this signifies abnormal HIT
• May not be an appropriate test for patients with neck pathology

Test of Skew (Cover Test)

• Have the patient look at your nose with their eyes; look for vertical ocular misalignment; cover one eye, and quickly look to see if the uncover eye moves to realign
• Test for both eyes

Central Vertigo

• Originating from the central nervous system (brainstem or cerebellum)
• Uncommon but more serious and should be ruled out immediately

Distinctive features

• Gradual or sudden onset
• Mild intensity
• Usually lasts for weeks to months but can be seconds to minutes with vascular causes
• Associated neurological findings are always present
• Usually no auditory findings except stroke involving anterior inferior cerebellar artery
• Dizzy spells described as lightheadedness
• Severe imbalance in which the patient cannot stand still or walk
• Characteristics of nystagmus:
  • Horizontal, rotary or vertical direction
  • Short latency
  • Sustained duration
  • Mild intensity
  • Nonfatigable
  • Not suppressed by visual fixation
• HIT, Nystagmus, Test of skew (HINTs) test that reveals negative head impulse test, central characteristic of nystagmus, positive test of skew

Common causes

• Migrainous vertigo
• Cerebrovascular disease (eg TIA, stroke)
• Multiple sclerosis

Please refer to separate disease management charts of the above causes for more detailed discussion

Peripheral Vertigo

• Originating from the labyrinth or vestibular nerve

Distinctive features

• Sudden in onset
• Severe intensity
• Usually lasts for seconds to minutes but occasionally from hours to days that occurs intermittently
• Absence of associated neurologic findings
• Auditory symptoms (eg hearing loss, tinnitus) may be present
• Dizziness is described as “rotating surrounding” or “the patient is spinning”
• Mild imbalance that the patient can still stand steadily or walk
• Nystagmus characteristics:
  • Either horizontal or upbeating-torsional nystagmus that beats to a unilateral direction even if the eye gazes to the left or right
  • Long latency
  • Transient duration
  • Mild to severe in intensity
  • Fatigable
  • Suppressed by visual fixation
• HINTs test that reveals positive head impulse test, peripheral characteristic of nystagmus, negative test of skew

Common causes differentiated by duration of vertigo

• Benign paroxysmal vertigo is the most common cause of vertigo that occurs for a few seconds
• Meniere’s disease with vertigo that lasts from minutes to hours
• Acute vestibular dysfunction with vertigo that can be felt from hours to days
  • Acute vestibular neuronitis
  • Acute labyrinthitis

Other peripheral causes

• Superior canal dehiscence (SCD)
• Cholesteatoma
• Herpes zoster oticus
• Otosclerosis
• Perilymphatic fistula
• Vestibular paroxysmia

Other Causes of Vertigo (not central or peripheral)

• Psychogenic (eg panic disorder, anxiety disorder, agoraphobia, depression)
• Drug-induced (eg aminoglycoside, Carbamazepine, Furosemide, Phenytoin, antidepressants, antihypertensives and cardiovascular medications)
• Cervical vertigo (triggered by somatosensory input from movement of head and neck)
• Visual vertigo (triggered by repetitive moving visual input)

Benign Paroxysmal Positional Vertigo

• Sudden or rapid spinning sensation due to change of head position relative to gravity
• It is a result of abnormal stimulation of the cupula within any of the 3 semicircular canals
• Due to entrapment of canalith in the semicircular canal
  • Canaliths are small crystals of calcium carbonate that have detached from the utricle in the vestibule of the inner ear

• Usually occur when rolling over in bed or when tilting the head to look upward or bending forward
• Types of benign paroxysmal vertigo (BPPV)
  
  • Posterior semicircular canal BPPV (posterior canal BPPV)
    • Most common type that is believed to be due to trapping of debris of fragmented endolymph particles in the posterior canal
  • Lateral semicircular canal BPPV (Horizontal canal BPPV)
    • Less common type that may be due to the same etiology of posterior canal BPPV but the pathophysiology is still not clear
  • Anterior canal BPPV
    • Usually transitory that results from “canal switching” that occurs in the course of treating other more common forms of benign paroxysmal vertigo

Diagnostic Tests

• Radiographic imaging and vestibular function testing is not needed if history and Dix-Hallpike maneuver confirms the diagnosis of benign paroxysmal vertigo
• There are no radiologic findings characteristic of or diagnostic for benign paroxysmal vertigo
• Audiometry is not required to diagnose benign paroxysmal vertigo however it may offer diagnostic benefit for patients in whom the clinical diagnosis of benign paroxysmal vertigo is unclear

Meniere’s Disease

• Also called endolymphatic hydrops
• Discrete episodic attacks characterized by sustained vertigo (lasting at least 20 minutes), fluctuating sensorineural hearing loss (confirmed by audiometric testing), low pitch tinnitus and aural fullness
• Caused by build up of endolymph (fluid in the inner ear) that distorts and distends the membranous labyrinthine system
• There is no definitive or specific diagnostic test for Meniere’s disease, diagnosis is based mostly on history and presenting clinical symptoms

Acute Vestibular Dysfunction

• Sudden, unanticipated, severe vertigo with a subjective sensation of rotational motion which are commonly preceded by a viral prodrome
• Composed of 2 disease entities:

Acute Vestibular Neuronitis

• Inflammation of the vestibular nerve usually caused by herpes virus
• Spontaneous, unidirectional, horizontal nystagmus in which the fast phase beats away from the affected ear
• At Romberg’s test, the patient tends to fall towards the affected side
• Inability to maintain visual fixation with rapid turning of the head toward the side of the lesion

Acute Labyrinthitis

• Infection of the inner ear that causes inflammation of the membranous labyrinth and damage to the vestibular and auditory end organs
• May be caused by viral or bacterial infection
• Vertigo is severe, often incapacitating and with sudden onset
• In many cases, the primary presenting symptom is hearing loss, not associated with ear fullness seen in Meniere’s disease
  • It is important to ask about hearing loss since this does not occur with benign paroxysmal vertigo or vestibular neuronitis

• Patient also experiences sudden unilateral loss of vestibular function
• Tinnitus may be present