Approach to dizziness and vertigo: Clinical sciences

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Introduction 0:00–0:32

Dizziness is a term used to describe symptoms such as loss of balance, lightheadedness, and altered spatial orientation, while vertigo refers to an abnormal sensation of self-motion or movement of the surrounding environment.
Now, dizziness can occur because of metabolic, cardiac, and neurologic conditions, while vertigo typically occurs due to vestibular or focal brain conditions.
Now, if your patient presents with dizziness or vertigo, the first step is to obtain a focused history and physical examination and establish which of these they are experiencing.

Dizziness 0:32–1:16

First, let’s focus on dizziness! In this case, your patient will describe lightheadedness, altered orientation of space, or feeling faint.
There will be no abnormal sensation of motion, but the patient might report feeling off-balance. In some cases, history might reveal nausea and vomiting, while the physical exam might demonstrate some degree of gait impairment and no nystagmus!
With these findings, diagnose dizziness, so be sure to assess the timing of symptoms, which could be episodic or persistent.
Let’s first take a look at episodic dizziness. If the dizziness is episodic, further assess the underlying cause with additional history and exam evaluation.

Episodic dizziness 1:16–1:35

Some common causes include orthostatic hypotension and panic disorder. First, let's discuss orthostatic hypotension...
Orthostatic hypotension is typically associated with dizziness when moving to an upright position, such as with sitting or standing up.

Orthostatic hypotension 1:35–2:52

The patient may feel their heart racing, or that they are about to pass out with a darkening of their vision. There might be a recent history of volume depletion, such as from vomiting, diarrhea, or blood loss.
Additionally, history might reveal neurologic conditions causing autonomic dysfunction, such as Parkinson disease, multiple system atrophy, and neuropathy.
The physical exam involves checking blood pressure in supine and standing positions. After standing up, the systolic blood pressure will drop at least 20 mmHg, or the diastolic blood pressure will drop at least 10 mmHg.
Additionally, you might notice a prolonged capillary refill time or pallor on exam. With these findings, diagnose orthostatic hypotension.
Now, here's a clinical pearl to keep in mind! In addition to orthostatic hypotension, other conditions that can cause dizziness due to transient hypoperfusion of the brain include cardiac conditions, such as arrhythmias, aortic stenosis, and heart failure.
Let’s now talk about panic disorder, which is associated with intense episodes of fear or discomfort that peak within minutes, known as panic attacks.

Panic disorder 2:52–3:17

The patient might also report shortness of breath or chest pain. Additionally, the physical exam will reveal tachycardia, sometimes in combination with diaphoresis and tremulousness.
With these findings, diagnose panic disorder. Now, switching gears and moving on to persistent dizziness.

Persistent dizziness / Medication side effect 3:17–4:04

If the dizziness is persistent, further assess the underlying cause with additional history and exam evaluation. First, let’s focus on the medication side effects!
Most commonly, your patient will be elderly and report symptoms that have started with the initiation of a new medication or an increase in medication dosage.
This is especially common with antihypertensive and antihistamine medications. The physical exam is typically normal, but sometimes it might reveal bradycardia or hypotension.
In this case, the probable cause of dizziness is a medication side effect. So, if possible, discontinue the medication, and if the dizziness resolves, you can be sure of the diagnosis!
Finally, let’s discuss post-concussion syndrome. In this case, your patient will report that the dizziness started after head trauma!

Post-concussion syndrome 4:04–4:35

Additionally, they might report headaches, sleep disturbance, mood changes, and trouble with attention or memory. Depending on the severity of the brain injury, the physical exam might reveal abnormal cognitive testing or a focal neurologic deficit.
With these findings, diagnose post-concussion syndrome. Now, let’s go back and take a look at individuals with vertigo!

Vertigo 4:35–5:03

In this case, your patient will describe an abnormal sensation of motion, such as spinning, tilting, or sinking. Often, your patient will report that they are feeling off-balance, and, in some cases, they might report nausea and vomiting.
The physical exam may demonstrate gait impairment or nystagmus. With these findings, you can diagnose vertigo, so your next step is to assess the timing of vertigo!
If vertigo is episodic, assess the underlying cause and consider two common conditions, which include benign paroxysmal positional vertigo, or BPPV for short, and Ménière disease.

Episodic vertigo 5:03–5:17

First, let’s discuss BPPV, which occurs due to the dislodgement of calcium carbonate crystals from the utricle into the semicircular canals, most commonly the posterior canal.

BPPV 5:17–6:58

Your patient will describe recurrent episodes of vertigo that last only seconds and occur when they change the head position.
Some examples include when sitting up in bed or lying down. Since the condition is limited to the vestibular organs, there will be no hearing loss or tinnitus.
During the physical exam, you should perform a Dix-Hallpike test. To perform the Dix-Hallpike test, have your patient sit.
Next, slightly extend their neck, turn it to one side, and rapidly place them in a supine position, so that their head hangs over the edge of the bed.
Keep your patient in this position for 30 seconds. If the head is turned towards the affected ear, the patient will report vertigo, and you will see nystagmus that is upbeating and torsional in the direction of the affected ear.
These findings are consistent with posterior canal involvement, meaning the Dix-Hallpike test is positive. With these findings, diagnose BPPV.
If there’s no nystagmus or vertigo, return the individual to the upright position and wait for another 30 seconds. After that, repeat the maneuver for the other side as well.
Here’s a clinical pearl to keep in mind! Once you diagnose BPPV, perform the Epley maneuver, which repositions the calcium carbonate crystals from the semicircular canals and helps relieve vertigo symptoms!
Alright, let’s switch gears and move on to Ménière disease, which is typically associated with recurrent episodes lasting minutes to hours with no apparent triggers.

Ménière disease 6:58–7:30

The patient will describe hearing loss, possibly tinnitus, and a sensation of ear pressure or fullness. These symptoms are thought to be due to an increase in endolymphatic fluid in the inner ear.
The physical exam will be notable for a negative Dix-Hallpike test. In this case, diagnose Ménière disease.
Finally, if your patient presents with persistent vertigo, consider acute vestibular syndrome, which can be either peripheral...or central!

Persistent vertigo 7:30–7:40

First, let’s focus on acute peripheral vestibular syndrome. In this case, your patient will report an acute new-onset vertigo!

Acute peripheral vestibular syndrome 7:40–9:29

Next, be sure to perform the HINTS exam, which consists of head impulse test, checking for nystagmus, and test of skew. First, let’s start with the head impulse test.
First, ask the patient to fixate on a target, such as your face, while you rapidly rotate their head to either side. In acute peripheral vestibular syndrome, the head impulse test will be positive, meaning you will detect a catch-up saccade after head rotation.
In other words, when you rotate the patient’s head towards the affected ear, the patient’s fixed gaze will momentarily break and move with their head but will subsequently rapidly go back to fixating on the target.
The physical exam will also reveal horizontal nystagmus beating away from the affected ear, regardless of the gaze direction, known as direction-fixed horizontal nystagmus.
Finally, perform the test of skew. First, ask your patient to focus their gaze on your nose.
Next, cover one of the patient’s eyes with a hand or an object for a couple of seconds. Next, uncover the eye, and cover the other one, while checking for vertical movement of the previously covered eye.
This is called the alternate cover test. In this case, the test is going to be normal, meaning there will be no vertical skew.
With these findings...diagnose an acute peripheral vestibular syndrome, so your next step is to perform the finger rub test to assess for hearing loss.
Perform this test on each side by rubbing your index finger and thumb close to the patient’s ear. If the patient can recognize the rubbing sound on each side, the finger rub test is normal, meaning there’s no hearing loss.

Vestibular neuritis 9:29–9:54

In this case, diagnose vestibular neuritis, which refers to the inflammation of the vestibular portion of the vestibulocochlear nerve.
Keep in mind that in most cases, these individuals will report a recent upper respiratory tract infection or viral illness.
On the flip side, if the finger rub test is abnormal, meaning the patient has hearing loss, diagnose labyrinthitis. In this case, inflammation involves the labyrinth of the ear, which contains both vestibular and cochlear organs, leading to balance and hearing issues.

Labyrinthitis 9:54–10:12

Finally, let’s discuss patients with acute central vestibular syndrome! In this case, the patient will report acute new-onset vertigo and their physical exam will reveal a negative head impulse test, meaning they can maintain a fixed gaze without catch-up saccades.

Acute central vestibular syndrome 10:12–11:14

Additionally, the exam will reveal direction-changing horizontal or vertical nystagmus. Finally, the test of skew will be abnormal, meaning you will notice vertical movement of the patient’s eyes on the alternate cover test.
In this case, diagnose an acute central vestibular syndrome, so be sure to obtain a brain MRI. Now, here’s a clinical pearl to keep in mind!
Patients with a central cause of acute vestibular syndrome often have additional neurologic signs and symptoms depending on the lesion location.
This means that your patient will often present with motor or sensory impairment, dysarthria, diplopia, and dysmetria. If the MRI shows infarction or hemorrhage in the brainstem or cerebellum, diagnose stroke as the cause.

Stroke 11:14–11:56

One important stroke syndrome associated with vertigo is called lateral medullary syndrome, also known as Wallenberg syndrome.
In this condition, the infarction of the vertebral artery or the posterior inferior cerebellar artery affects the lateral medulla and results in loss of pain and temperature sensation over the ipsilateral face and contralateral body.
Other important findings include hiccups, dysarthria, hoarseness, as well as ipsilateral Horner syndrome and ataxia. On the other hand, if the MRI shows multiple white matter lesions, some of which are enhancing, think of demyelination, such as multiple sclerosis.

Demyelination 11:56–12:28

Here’s one last clinical pearl! There are also chronic vestibular syndromes, which are typically associated with cerebellar tumors or tumors of the cerebellopontine angle.
A patient with a cerebellopontine angle tumor will also likely present with ipsilateral upper and lower facial weakness.
Alright, as a quick recap… Dizziness is a term used to describe symptoms such as loss of balance, lightheadedness, and altered spatial orientation, while vertigo refers to an abnormal sensation of self-motion or movement of the surrounding environment.

Review 12:28–13:08

Dizziness can be episodic, which is common in orthostatic hypotension and panic disorders, and persistent, which is usually associated with medication side effects and post-concussion syndrome.
On the flip side, vertigo can be classified as episodic, which is common in BPPV and Ménière disease, or persistent, which can be either acute peripheral or central
Approach to dizziness and vertigo: Video and Steps | Osmosis