Vertigo is described as an “abnormal sensation of motion. It can occur in the absence of motion or when motion is sensed inaccurately”¹

Assessing a patient with vertigo can be challenging, even for experienced clinicians. Patients often use the words “vertigo” and “dizziness” synonymously to describe their symptoms, but the sensations they are experiencing can vary widely: unsteadiness, feeling lightheaded, or a sensation of imbalance may all be described as dizziness.

In terms of management, it is important to differentiate between these symptoms and true vertigo. It helps to pin down early in the history exactly what sensations the patient experiences when they say that they have “vertigo” or they feel “dizzy”, to guide your differential and help you manage the patient appropriately.

Below are some key pointers to consider when assessing the patient.

History

• Firstly, ask the patient to describe exactly what they mean when they say they feel dizzy (they may find it tricky to put into words, but encourage them to try!)
  • Light headed/faint/blurred vision: pre-syncopal episodes, postural hypotension, cardiac cause.
  • Unsteady/sensation of imbalance.
  • Room spinning/sensation of the floor moving/veering off to one side when they walk (more suggestive of true vertigo/vestibular disorders.)
• Onset of symptoms
• Are the symptoms continuous or Intermittent? Duration of the symptoms is very important in determining the likely diagnosis in peripheral vertigo:
  • Seconds: Bening Paroxysmal Positional Vertigo (BPPV)
  • Minutes to Hours: Meniere’s
  • Days to Weeks: Labyrinthitis or Vestibular Neuritis
• What are the triggers?
  • Head-turning/ rolling over in bed is suggestive of BPPV
• Are there any associated symptoms?
  • Fever? Generally unwell? Coryzal?
  • Neurological symptoms: dysphagia, limb weakness or stroke risk factors.
  • ENT symptoms: ear pain, discharge, ear fullness hearing loss, tinnitus or history of ear surgery.
• Have there been any previous episodes?
• Drug history
  • Any recent changes to medications?
  • Have they tried any treatments to date?

Examination

• Carry out a full neurological examination as well as an examination of the eyes and ears
• A ‘Head Impulse Nystagmus Test of Skew’ (HINTS) exam (see video) can be used to differentiate between central and peripheral vertigo. It is only used on patients experiencing symptoms at the time of the assessment
• Specific clinical tests:
  • Romberg’s test – Ask the patient to stand with their eyes closed, feet together and arms outstretched.
    • Positive if the patient is unable to maintain balance. This suggests proprioception or vestibular issue.
  • Unterberger step test – Ask the patient to march on the spot for 30 seconds with their eyes closed. If there is labyrinth dysfunction, the patient will turn to the affected side.
  • Dix Hallpike manoeuvre – To diagnose BPPV. Some patients are able to teach themselves the manoeuvres.

Differential Diagnoses

Central

• Postural hypotension
• Stroke/Transient Ischaemic Attack (TIA)
• Arrhythmias
• Migraine
• Multiple sclerosis
• Space occupying lesion
• Medication Age-related Disequilibrium

Peripheral

• Benign Paroxysmal Positional Vertigo (BPPV)
• Meniere’s Disease
• Viral Labyrinthitis
• Vestibular Neuronitis
• Vestibular Schwannoma Ear infection (Otitis media/ otitis externa)

Management

• The management will depend on the diagnosis that is made.
• Vestibular sedatives such as prochlorperazine and betahistine, may be used to manage the patients symptomatically. However, these should be used with caution and for short courses only, as dampening the sensory input to the vestibular system may exacerbate symptoms in the long term.
• Dizzy patients presenting acutely will often be managed by the emergency department/medics initially (unless there are associated ENT symptoms such as ear pain/ discharge).
• If central causes of vertigo have been ruled, out a referral to ENT may be warranted for further investigation.
• In most hospitals, ENT will review patients as an outpatient, often at dedicated Balance clinics where they have access to specialist vestibular testing, and support from audiology and vestibular physiotherapy.

Key points

• Taking a precise history will help you determine whether there is true vertigo.
• Using your precise history, it is then important to differentiate between central or peripheral causes (HINTS examination)
• Vestibular sedatives may be useful but only in limited courses.
• Don’t panic if you don’t know exactly the cause of a patient’s vertigo after assessing them. The main priority is ruling out a central cause (particular a stroke).
• If you have any doubts, discuss with your SHO or registrar.

References

1. Konrad HR. Vertigo and Associated Symptoms. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 123. Available from: https://www.ncbi.nlm.nih.gov/books/NBK228/
2. ENT UK – Vertigo
3. Patient – Vertigo
4. ENT SHO – Dizziness

Written by Jennifer Wallace ENT CT2
Edited by Mudassar Khan (Y3 Medical Student)