A 44-year-old man had recurrent dizziness and subjective sensation of profound environmental spin. He had occasional off and on high-pitched ringing in both ears. Past medical history was noteworthy for deep vein thrombosis of the lower extremity 11 years earlier following a limb fracture. Neurologic and neurootologic examinations were normal.

Our patient presented with a 1-year history of intermittent vertiginous dizziness. He had no hearing loss or ear fullness, but described an occasional high-pitched ringing in both ears. Magnetic resonance imaging (MRI) scan of the brain with and without contrast and additional extensive laboratory evaluation showed no apparent etiology for his vertigo.

The main categories of dizziness are vertigo, presyncopal dizziness (impending faint), disequilibrium (poor balance), and a nonspecific group. Vertigo is an illusion of spinning or motion, ranging from mild to severe. Peripheral vestibular afferents innervate the brainstem vestibular nuclei and project to the cerebellum, oculomotor nuclei, cerebral areas, and spinal cord. Otologic or peripheral vertigo may be present with pathology involving the labyrinth or the vestibular nerve and is often characterized
by intense episodic vertigo, often leaving the patient immobile from the attack. There is often nausea, vomiting, tachycardia, and diaphoresis. In contrast, patients with presyncopal dizziness experience light-headedness, often postural, as if they might pass out. Causes of presyncopal dizziness include orthostatic hypotension, autonomic neuropathy, use of antihypertensive medications, vasovagal attacks, and cardiac arrhythmias.