An Approach to Vertigo
A 65-year-old female with no significant past medical history presents with dizziness. Patient states that she was on her computer paying bills roughly 30 minutes earlier when she started to suffer some eye-strain. She stood up and walked over to her recliner. Upon sitting on the recliner, she began to experience a few minutes of dizziness, which she describes the room spinning. The patient states that after laying in the recliner for some time, the dizziness resolved. But as she sat back up to get up out of the recliner, she began experiencing the dizziness again, which lasted for a few minutes.
The patient denies any changes in hearing, chest pain, shortness of breath, abdominal pain, nausea, or vomiting during the episodes. The patient states that afterwards she did feel a bit fatigued. She denies any fevers, recent illnesses, sick contacts, international, or travel. She denies any head trauma and states that she woke up today in her normal state of health. She does not take any medications.
Take Away #1 - Determine what the patient means by dizziness:
The feeling of passing out/lightheadedness → pre-syncope vs syncope
Feeling unsteady or the room spinning → Vertigo
Regardless, everyone should get an EKG and even a finger stick
The physical exam includes a complete ear exam and neurological exam with cerebellar assessment (heal-to-shin, finger-to-nose, and ambulation)
Take Away #2 - Determine Central vs Peripheral Cause of Vertigo
Sudden onset, prolonged duration, less intense vertigo, variable nausea or vomiting, vertical or bidirectional nystagmus, focal neurologic deficits present, usually no auditory symptoms, and a normal head impulse test
Typically requires imaging like an CT/CTA or MRI/MRA of head and neck along with basic labs
Sudden or insidious onset, short and fleeting symptoms associated with posture, intense vertigo, frequent nausea or vomiting, unidirectional rotatory and horizontal nystagmus, no focal neurologic deficits, and frequent auditory symptoms like tinnitus and hearing loss
Benign paroxysmal peripheral vertigo (BPPV)
Pathophysiology: dislodgment of otoliths [calcium carbonate] from utricle into the semicircular canal
Recurrent and most reproducible, more prevalent with age
Vestibular Neuronitis/Labyrinthitis (inflammation of vestibularcochlear nerve)
The second most common cause of peripheral vertigo presents with more chronic and prolonged dizziness which can be concerning so utilization of the HINTS exam is helpful
Drugs like aminogylcocides
Take Away #3 - Determine the appropriate physical exam
Sudden or insidious, fleeting symptoms associated with posture are likely due to a peripheral cause.
The gold standard diagnostic tool is via the Dix-Hallpike, a series of guided physical movements that elicits a particular physical response.
The down ear toward the side of the fast phase of the rotary nystagmus is the affected side.
A positive test being when the patient experiences short lived unidirectional rotary/horizontal nystagmus allowing up to 20 seconds of latency for symptoms to begin and repeat maneuver on opposite side.
Have the patient seated with head turned 45 degrees to the right and lower the patient to supine position with head hanging over the edge of the bed and the neck in 20 degrees of extension
The Epley Maneuver
The Epley maneuver is a series of movements to help coax the otoliths out of the semicircular canal.
After nystagmus and symptoms resolve (or 30 to 60 seconds), return the patient to a sitting position with legs dangling off the side of the table and the head to the midline
After nystagmus and symptoms resolve (or 30 to 60 seconds), roll the patient onto the shoulder of the unaffected side as the head turns a further 90° so it is nearly facedown.
Quickly bring the patient to the recumbent position with the head hanging 20° below the examining table. After nystagmus and symptoms resolve (or 30 to 60 seconds) gently rotate the head 90° to the unaffected side.
With the patient seated, turn the head 45° toward the affected ear. (The affected ear is determined by the direction in which the Dix–Hallpike position test is positive.
Sudden, persistent vertigo with bidirectional nystagmus and focal neurological findings point towards a central cause.
Head Impulse, Nystagmus, Test of Skew
The HINTS exam should be used on patients with persistent and active dizziness and nystagmus.
Head impulse to test the vestibulo-ocular reflex.
Have patient fixate on your nose
Quickly move the patient's head from side to side looking for saccade while they continue to focus on your nose when bringing head back midline.
It is important to be unpredictable because the brain can compensate for the impulse, which points towards a functional vestibular system and a central etiology
A reassuring exam is when the patient has saccade (abnormal reflex), which points to a peripheral etiology
Have the patient stare off in the distance in primary, right, and left gaze
It is reassuring to see no nystagmus (normal) or horizontal uni-directional nystagmus
Nystagmus that is bidirectional or vertical is typically pathologic
Test of Skew
Have the patient fixate on your nose
Cover one eye and then quickly uncover it to assess if the eyes re-align
Repeat on the other side
Vertical or diagonal disconjugate gaze (skew) is pathologic for a central lesion
Kingsley Boateng, MD is a current first-year resident at Stony Brook Emergency Medicine.
Rosens emergency medicine. Philadelphia.
Tintinallis emergency medicine manual. New York: McGraw-Hill Education.
Edited by Bassam Zahid, MD