The clinical approach

Question 1

History

Answer 1

It is important to get patients to explain the precise
nature of the symptoms, even asking their opinion as
to the cause of their dizziness.

Question 2

Key questions

Answer 2

• Is it vertigo or pseudovertigo? 
 • Symptom pattern:
 — paroxysmal or continuous? 
 — effect of position and change of posture? 
 • Any aural symptoms? Tinnitus? Deafness? 
 • Any visual symptoms? 
 • Any neurological symptoms? 
 • Any nausea or vomiting? 
 • Any symptoms of psychoneurosis? 
 • Any recent colds? 
 • Any recent head injury (even trivial)? 
 • Any drugs being taken?
 — alcohol? 
 — marijuana? 
 — hypotensives? 
 — psychotropics? 
 — other drugs?

Question 3

Examination guidelines are

Answer 3

1) ear disease:
 • auroscopic examination: ? wax ? drum 
 • hearing tests 
 • Weber and Rinne tests 
 2) the eyes:
 • visual acuity 
 • test movements for nystagmus 
 3) cardiovascular system:
 • evidence of atherosclerosis 
 • blood pressure: supine, standing, sitting 
 • cardiac arrhythmias 
 4) cranial nerves:
 • 2nd, 3rd, 4th, 6th and 7th 
 • corneal response for 5th 
 • 8th—auditory nerve 
 5) the cerebellum or its connections:
 • gait 
 • coordination 
 • reflexes 
 • Romberg test 
 • finger nose test: ? past pointing 
 6) the neck, including cervical spine 
 7) general search for evidence of:
 • anaemia 
 • polycythaemia 
 • alcohol dependence

Question 4

Office tests for dizziness

Answer 4

1. Ask the patient to perform any manoeuvre that may provoke the symptom.
2. Carry out head positional testing to induce vertigo and/or nystagmus (e.g. Hallpike manoeuvre) . Avoid if prominent spontaneous vertigo and nystagmus.
3. BP measurements in three positions
4. Perform forced hyperventilation (20 to 25 breaths per minute) for 2 minutes.
5. Carry out palpation of carotid arteries and carotid sinus (with care)

Question 5

Investigations

Answer 5

Haemoglobin
Blood glucose
ECG: ? Holter monitor
Audiometry
Brain-stem evoked audiometry
Caloric test
Visual evoked potentials (MS)
Electrocochleography
Electro-oculography (electronystagmography)
Rotational tests
Radiology:
• chest X-ray (? bronchial carcinoma)
• cervical spine X-ray
• CT scan
• MRI (the choice to locate acoustic neuroma or other 
tumour—may detect MS and vascular infarction

Question 6

Diagnostic guidelines

Answer 6

1. A sudden attack of vertigo in a young person following a recent URTI is suggestive of vestibular neuronitis.
2. Dizziness is a common symptom in menopausal women and is often associated with other features of vasomotor instability.
3. Phenytoin therapy can cause cerebellar dysfunction
4. Postural and exercise hypotension are relatively common in the older atherosclerotic patient.
5. Acute otitis media does not cause vertigo but chronic otitis media can, particularly if the patient develops a cholesteatoma, which then erodes into the internal ear causing a perilymphatic fistula

Question 7

Dizziness in children

Answer 7

Not a common symptom in children.
Vertigo can have sinister causes and requires referral because of the possibility of tumours, such as a medulloblastoma.

Commonest cause was a seizure focus particularly affecting the temporal lobe. Other causes included:
• psychosomatic vertigo
• vestibular migraine
• vestibular neuritis.
• infection (e.g. meningitis, meningoencephalitis, cerebral abscess)
• trauma, especially to the temporal area
• middle-ear infection
• labyrinthitis (e.g. mumps, measles, influenza)
• BPPV (short-lived attacks of vertigo in young children between 1 and 4 years of age: tends to precede adulthood migraine)
• hyperventilation
• drugs—prescribed
• illicit drugs (e.g. cocaine, marijuana)
• cardiac arrhythmias
• alcohol toxicity. A common trap is the acute effect of alcohol in curious children who can present with the sudden onset of dizziness

Question 8

Dizzy turns in girls in late teens

Answer 8

• These are commonly due to blood pressure
fluctuations.
• Give advice related to reducing stress, lack of
sleep and excessive exercise.
• Reassure that it settles with age (rare after
25 years)

Question 9

Dizziness in the elderly

Answer 9

Relatively common complaint. Common causes include;
• Postural hypotension related mainly to drugs.
• Cerebrovascular disease, especially in the areas of the brain stem
• True vertigo can be produced simply by an accumulation of wax in the external auditory meatus, being more frequent than generally appreciated.
• Middle-ear disorder is also sometimes the cause of vertigo
• Disorder of the auditory nerve, inner ear, cerebellum, brain stem and cervical spine
• Malignancy, primary and secondary
• Cardiac arrhythmias as a cause of syncopal symptoms increases with age

If no cause such as hypertension is found, advise
them to get up slowly from sitting or lying, and to
wear firm elastic stockings.