Diagnostic Approaches to the Patient with Dizziness

Tae-Kyeong Lee; Ki-Bum Sung

doi:10.5124/jkma.2008.51.11.960

Journal List > J Korean Med Assoc > v.51(11) > 1042089

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Lee and Sung: Diagnostic Approaches to the Patient with Dizziness

Focused Issue of This Month

Diagnosis and Treatment of Dizziness

Journal of the Korean Medical Association

Journal of the Korean Medical Association 2008; 51(11): 960-974.

Published online: 30 November 2008

DOI: https://doi.org/10.5124/jkma.2008.51.11.960

Diagnostic Approaches to the Patient with Dizziness

Tae-Kyeong Lee, MD, Ki-Bum Sung, MD

Department of Neurology, Soonchunhyang University College of Medicine, Korea. sungkb@schbc.ac.kr

Abstract

Dizziness is one of the most commonly presenting complaints in clinical practice. However, a systematic diagnostic approach to the dizzy patient remains challenging due to the wide range of diagnostic possibilities. As a symptom, dizziness is quite subjective and is resulted from diverse conditions. Therefore, classifying the patient's complaints into the etiology oriented categories through detailed histories should be the first step of the approach. Physicians should be acquainted with skills for the history taking and a brief but comprehensive neuro-otologic examination which can be done easily in clinical practice. This article focused on practical skills for history taking and bedside examination in the diagnostic approaches to the patient with dizziness.

Keywords: Dizziness, Diagnostic approach, Neuro-otologic examination, Vestibulo-ocular reflex, Vestibular disorders

Figures and Tables

Table 1

Subtypes of dizziness

BPPV: benign paroxysmal positioning vertigo, VN: vestibular neuritis, MD: meniere's disease, MD: migrainous vertigo, VBI: vertebrobasialr insufficiency, OH: orthostatic hypotension, CHF: congestive heart failure.

Table 2

Differences between central and peripheral positional vertigo

Table 3

Differential points between central and peripheral vertigo

Table 4

Evaluation of static and dynamic vestibular imbalance

Table 5

Differences between central and peripheral nystagmus

Table 6

Pattern of nystagmus after horizontal head shaking

Table 7

Routine neuro-otologic tests

References

1. Brandt T, Strupp M. General vestibular testing. Clin Neurophysiol. 2005. 116:406–425.

2. Kroenke K, Mangelsdorff D. Common symptoms in ambulatory care: incidence, evaluation, therapy and outcome. Am J Med. 1989. 86:262–266.

3. Tusa RJ. Dizziness. Med Clin N Am. 2003. 87:609–641.

4. Neuhauser HK. Epidemiology of vertigo. Curr Opin Neurol. 2007. 20:40–46.

5. Brandt T. Vertigo. Its multisensory syndromes. 1999. 2nd eds. Berlin: Springer.

6. Sung KB, Park SA, Lee TK. Understanding of dizzines. J Korean Bal Soc. 2002. 1:157–164.

7. Nazareth I, Landau S, Yardley L, Luxon L. Patterns of presentation of dizziness in primary care--a cross-sectional cluster analysis study. J Psychosom Res. 2006. 60:395–401.

8. Lee TK, Sung KB. Clinical approach to the patient with dizziness. J Korean Neurol Assoc. 2008. 26:S. 490–497.

9. Lee TK, Sung KB. Diagnosis of acute spontaneous vertigo. J Korean Neurol Assoc. 2007. 25:S. 47–53.

10. Amarecnco P, Rolullet E, Hommel M, Chain P, Marteau R. Infarction in the territory of the medial branch of the posterior inferior cerebellar artery. J Neurol Neurosurg psychiatry. 1990. 53:731–735.

11. Lee H, Cho YW. A case of Isolated nodulus infarction presenting as a vestibular neuritis. J Neuro Sci. 2004. 221:117–119.

12. Norrving B, Magnusson M, Holtas S. Isolated acute vertigo in the elderly; vestibular or vascular disease? Acta Neurol Scand. 1995. 91:43–48.

13. Lee H, Yi HA, Cho YW, Sohn CH, Whitman GT, Ying S, Lee H, Yi HA, Cho YW, Sohn CH, Whitman GT, Ying S, Baloh RW. Nodulus infarction mimicking acute peripheral vestibulopathy. Neurology. 2003. 60:1700–1702.

14. Lee H, Sohn SI, Jung DK, Cho YW, Lim JG, Yi SD, Lee H, Sohn SI, Jung DK, Cho YW, Lim JG, Yi SD, Lee SR, Sohn CH, Baloh RW. Sudden deafness and anterior inferior cerebellar artery infarction. Stroke. 2002. 33:2807–2812.

15. Ropper AH, Brown RH. Deafness, dizziness, and disorders of equilibrium. Principles of Neurology. 2005. 8th. eds. Mcgraw Hill;246–268.

16. Neuhauser H, Lempert T. Vertigo and dizziness related to migraine: A diagnostic challenge. Cephlalgia. 2004. 24:83–91.

17. Neuhauser H, Heopold M, von Brevern M, Arnold G, Lempert T. The interrelations of migraine, vertigo, and migrainous vertigo. Neurology. 2001. 56:436–441.

18. Johnson GD. Medical management of migraine-related dizziness and vertigo. Laryngoscope. 1998. S. 1–28.

19. Committee on hearing and equilibrium. Menier's disease: Guideline for the diagnosis and evaluation of therapy for reporting. Otolaryngol Head Neck Surg. 1995. 113:181–185.

20. Baloh RW. Vertebrobasilar insufficiency and stroke. Otolaryngol Head Neck Surg. 1995. 112:114–118.

21. Grad A, Baloh RW. Vertigo of vascular origin: clinical and electronystagmographic features in 84 cases. Arch Neurol. 1989. 46:281–284.

22. Baloh RW, Honrubia V, Jacobson K. Benign positional vertigo: clinical and oculographic features in 240 cases. Neurology. 1987. 37:371–378.

23. Epley JM. Positional vertigo related to semicircular cacalithiasis. Otolaryngol Head Neck Surg. 1995. 112:154–161.

24. Schuknecht HF. Cupulolithiasis. Arch Otolaryngol. 1969. 90:765–778.

25. Dix R, Hallpike CS. The pathology, symptomatology, and diagnosis of certain common disorders of the vestibular system. Proc R Soc Med. 1952. 54:341–354.

26. Baloh RW, Jacobson K, Honrubia V. Horizontal semicircular canal variant of benign positional vertigo. Neurology. 1993. 43:2542–2549.

27. Baloh RW, Yue Q, Jacobson KM, Honrubia V. Persistent direction-changing postional nystagmus: Another variant of benign positional nystagmus? Neurology. 1995. 45:1297–1301.

28. Joseph D, Ristow G, Ward R. Managing a complaint of "dizziness" efficiently. Patient Care. 1987. 21:99–114.

29. Wennmo K, Wennmo C. Drug-related dizziness. Acta Otolaryngol. 1988. 455:11–13.

30. Brandt T, Daroff R. The multisensory physiological and pathological vertigo syndrome. Ann Neurol. 1980. 7:195–203.

31. Myeres R. Ototoxic effects of gentamycin. Arch otolaryngol. 1970. 92:160–162.

32. Beal A Jr, Glorig A. Dysequilibrium of ageing (presbyastasis). J Laryngol Otol. 1986. 100:1037–1041.

33. Tinetti ME, Williams CS, Gill TM. Dizziness among older adults: a possible geriatric syndrome. Ann Inern Med. 2000. 132:337–344.

34. Baloh RW. Dizziness in older people. J Am Geriatr Soc. 1992. 40:13–21.

35. Sloane PD, Hartman M, Mitchell CM. Psychological factors associated with chronic dizziness in patients aged 60 and older. J Am Geriatr Soc. 1994. 42:847–852.

36. Furman JM, Cass SP. Vestibular disorders; a case-study approach. 2003. Philadelphia: FA Davis.

37. Halmagyi GM, Curthoys IS. A clinical sign of canal paresis. Arch Neurol. 1988. 45:737–739.

38. Baloh RW, Honrubia V. Bedside examination of the vestbular system. Clinical neurophysiology of the vestibular system. 2001. 3rd eds. Oxford: Oxford University Press;132–151.

39. Zee DS. Miller AE, editor. Pathophysiology of vestibular symtoms and signs: The clinical examination. Neuro-otology Continuum. 2006. 12:Lippincott Williams & Wilkins;13–31.

40. Sung KB, Lee TK, Furman JM. Abnormal eye movements in dizzy patients. Neurologic Clinics. 2005. 23:675–703.

41. Sung KB. Rhee CK, editor. Nystagmus. Dizziness. 2007. Dankook University Press;111–143.

42. Robinson DA, Zee DS, Hain TC. Alexander's law: Its behavior and origin in the human vestibuloocular reflex. Ann Neurol. 1984. 16:714–722.

43. Brandt T, Dieterich M. Vestibular syndrome in the roll plane: Topographic diagnosis from brainstem to cortex. Ann Neurol. 1994. 36:337–347.

44. Bance ML, O'Driscoll M, Patel N, Ramsden RT. Vestibular diseases unmasked by hyperventilation. Laryngoscope. 1998. 108:610–614.

45. Yagi T, Ohyama Y. Three-dimensional analysis of nystagmus induced by neck vibration. Acta Otolaryngol (Stockh). 1996. 116:167–169.

46. Rottach KG, von Maydell RD, DiScenna AO, Zivotofsky AZ, Averbuch-Heller L, Leigh RJ. Quantitative measurements of eye movements in a patient with Tullio phenomenon. J Vestibul Res. 1996. 6:255–259.

47. Takahashi S, Fetter M, Koening E, Dichgans J. The clinical significance of head-shaking nystagmus in the dizzy patient. Acta Otolaryngol (Stockh). 1990. 109:8–14.

48. Demur JL, Honrubia V, Baloh RW. Dynamic visual acuity: a test for oscillopsia and vestibulo-ocular reflex function. Am J Otol. 1994. 15:340–347.

49. Fukuda T. Vertical writing with eyes covered: a new test of vestibulospinal reaction. Acta Otolaryngol (Stockh). 1959. 50:26–31.

50. Horak FB, et al. Vestibular and somatosensory contributions to response to head and body displacements in stance. Exp Brain Res. 1994. 100:93–97.

TOOLS

Similar articles