Vertigo-Dizziness
William Osler once was quoted as saying that no physician can hear the presenting complaint of “dizziness” without experiencing a sinking feeling. Although dizziness as a presentation is one of the most common in medicine, most physicians are uncomfortable with the diagnosis of this complaint.
The analysis of dizziness starts with having the patient define what he or she means by dizziness. Ask the patient to define his or her dizziness.
Dizziness is a nonspecific description of a variety of bodily sensations. Most patients, when asked, can describe their sensations more specifically and usefully. Do not allow the patient to get away with just saying “dizziness.”
Vertigo: a sense of spinning of self, or the environment. Vertigo indicates a vestibular system disorder.
Light-headedness: a feeling of faintness, or that one might pass out. This is associated with reduced perfusion to the brain from a variety of causes.
Unsteadiness: a feeling that one cannot stand or walk reliably. Unsteadiness may be caused by a variety of neurologic problems.
Wooziness: a less well-defined feeling of being “not right” or “unwell,” sometimes indicating anxiety.
ASSESSING VERTIGO
Vertigo implies a problem in the vestibular system. A disorder in the ear, eighth nerve, brainstem, or temporal lobe (the vestibular system) can cause vertigo. Occasionally, cervical disorders can cause vertigo by alteration of afferent sensory flow from receptors in the neck muscles (cervicogenic vertigo).
An important task is to decide whether the cause is peripheral (labyrinth, vestibular, or cochlear nerve) or central (brainstem, cerebellum, or cerebral cortex).
History of Vertigo
Questions to ask:
Does the vertigo last seconds, and is it related to a change in head position? (Positional vertigo).
Is there associated nausea, vomiting, or headache? (These may be seen with migraine or intracranial processes.)
Are symptoms of diplopia, dysarthria, focal weakness, or numbness present? (These suggest a brainstem lesion.)
Is there tinnitus or deafness? (These suggest eighth nerve or ear involvement.)
Is the patient taking many medications? (Medications may cause vertigo.).
Examination of the Vertiginous Patient
Specifically check the ear canal and hearing (listening to a watch tick, the spoken voice, and finger-rubbing screens three basic frequencies).
Perform a complete neurologic examination with special attention to cranial nerves, coordination, and the presence of nystagmus (horizontal, vertical, or rotatory).
Check for positional vertigo and nystagmus by having the patient go from a sitting to a supine position, while quickly turning the head to the side and with the neck extended 30 degrees. Note nystagmus, latency of the response, associated vertigo, and fatigability of the response.
Caloric testing (minimal ice water caloric test) may be performed. Patient lies supine with the head elevated 30 degrees. Irrigate each ear with 0.2 mL ice water (tuberculin syringe). Notice any asymmetry between the response in each ear.
Is the Vertigo Peripheral or Central in Origin?
With vertigo, a major goal of the clinician is to decide whether the lesion is peripheral (labyrinth, vestibular, or cochlear nerve) or central (brainstem, cerebellum, or cerebral cortex). A careful history is often helpful in making this distinction.
Peripheral lesions causing vertigo may be associated with deafness and tinnitus (signs of eighth-nerve dysfunction); there are no central signs. If caloric testing reproduces the patient’s dizziness or there is a unilaterally decreased caloric response, the lesion is usually peripheral. Central lesions are defined by central nervous system (CNS) signs or symptoms (e.g., ataxia, cranial nerve abnormalities, diplopia, dysarthria, papilledema). In peripheral vestibulopathy,
the patient falls toward the side of the lesion and away from the fast component of nystagmus. In central lesions such as cerebellar infarction, the patient falls toward the side of the lesion and toward the fast component of nystagmus. Vertical nystagmus is a sign of brainstem disease unless the patient is taking medication (especially barbiturates). Rotary or torsional nystagmus generally is seen with peripheral lesions.
the patient falls toward the side of the lesion and away from the fast component of nystagmus. In central lesions such as cerebellar infarction, the patient falls toward the side of the lesion and toward the fast component of nystagmus. Vertical nystagmus is a sign of brainstem disease unless the patient is taking medication (especially barbiturates). Rotary or torsional nystagmus generally is seen with peripheral lesions.
Testing for Positional Nystagmus
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