Assessment of dizziness

Overview
Summary Aetiology

Emergencies
Urgent considerations

Diagnosis
Step-by-step Differential diagnosis Guidelines

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Summary
Dizziness is a non-specific term and may be used by patients to indicate true vertigo, lightheadedness, imbalance, or a form of syncope. The prevalence of dizziness in the general population ranges from 20% to 30%. [1] True vertigo is described as a rotary sensation of the patient or surroundings, and is often of vestibular origin.

Aetiology
The aetiology varies from vestibular to neurological to cardiovascular pathology. The most common causes of vertigo are migraine-related vertigo, benign positional paroxysmal vertigo (BPPV), and Meniere's disease. Cerebellar infarct or vestibular schwannoma (acoustic neuroma) may also cause dizziness.

History and clinical findings

It is important to take a detailed history of the patient's symptoms. True vertigo often indicates vestibular pathology (e.g., BPPV, labyrinthitis, or Meniere's disease). Central pathology, such as a cerebellar ischaemic stroke, needs to be ruled out. A description of the typical attacks, including their nature, duration, and associated auditory symptoms (e.g., hearing loss, tinnitus, and aural pressure), should be determined. Physical examination includes an ear and neurological examination plus an examination of the vestibular system. Neurological examination is important to rule out central pathology. The Dix-Hallpike test should be carried out if BPPV is suspected.

Investigations
The diagnosis of dizziness is usually made on the basis of the history and examination only. Investigations may not be necessary. Magnetic resonance imaging (MRI) of the brain and internal auditory meatus should be carried

out if there is concern that there may be central pathology. Vestibular function tests are indicated in some cases. Tests of cardiovascular function may be necessary if a cardiovascular cause is suspected.

Aetiology
Dizziness has a variety of aetiologies. True vertigo (spinning sensation) indicates a problem with the vestibular system (peripheral or central). Dizziness or lightheadedness may be cardiovascular in origin or associated with infectious, metabolic, or autoimmune disease or with medications.

Vestibular
Benign positional paroxysmal vertigo: the most common cause of vertigo, affecting 107 cases per 100,000 per year. [2] The lifetime prevalence is 2.4%. [3] It is caused by loose otoconia particles in the semicircular canals, usually the posterior canal but sometimes the lateral canal. It is diagnosed by the Dix-Hallpike test for posterior canal BPPV. If the Dix-Hallpike test is negative in a patient with a compatible history, a supine roll test should be done to assess the patient for horizontal canal BPPV. [4] [3] Meniere's disease: occurs in 1% of the population and affects all ages. [5] It is idiopathic but is associated with endolymphatic hydrops. Meniere's disease is characterised by episodic vertigo, fluctuating hearing loss, tinnitus, and aural pressure or fullness. [5] Other specific disorders affecting the inner ear and associated with hydrops are temporal bone fracture, syphilis, hypothyroidism, Cogan's syndrome, and Mondini's dysplasia. Labyrinthitis: an acute infection of the vestibular organs, most commonly bacterial or viral. The patient often presents after an upper respiratory or ear infection. [6] Vestibular neuritis (neuronitis): an acute peripheral vestibulopathy due to reactivation of a viral infection, most commonly herpes simplex virus, which affects the vestibular ganglion, vestibular nerve, labyrinth, or a combination of these sites. Superior semi-circular canal dehiscence: characterised by episodes of vertigo associated with loud sound and/or altered middle-ear pressure. Auditory complaints include hyperacusis to bone-conducted sounds, a conductive hearing loss, and normal acoustic reflexes. Many patients with superior semi-circular canal dehiscence present after head trauma, and their dizziness may initially be thought to be post-traumatic vertigo, labyrinthine concussion, or perilymphatic fistula. The diagnosis is supported by evidence of bony dehiscence of the superior semi-circular canal on high-resolution computed tomography scan of the petrous temporal bones. In addition, the vestibular-evoked myogenic potential may be abnormal. [7] Perilymphatic fistula: occurs either in the round or oval window. It may occur after stapes surgery or head trauma or in divers. It is characterised by paroxysmal vertigo, imbalance, and a sensorineural hearing loss with or without tinnitus. [8] The diagnosis is made at surgery (exploratory tympanotomy).

Middle-ear disease: acute bacterial otitis media and labyrinthitis may present with dizziness.[6] Other middle-ear disease, such as cholesteatoma, may be associated with vertigo. Patients who have had previous mastoid surgery with a mastoid cavity are prone to dizziness with an ear infection.

Neurological
Migraine-related vestibulopathy: often occurs in patients with a personal or family history of migraine. It is one of the most common causes of vertigo and dizziness. There are different theories for the pathophysiology of migraine-associated vestibulopathy. These include a spreading, global central nervous system (CNS) depression to account for central findings, and vasospasm of the internal auditory artery to account for peripheral cochleovestibular symptoms. Others attribute the central and peripheral symptoms to deficits in the release of neuropeptides during an attack. [9] Posterior fossa tumours: include vestibular schwannomas (acoustic neuroma), meningiomas, cerebellar or brainstem tumours, and epidermoid cysts. Multiple sclerosis: vertigo is an initial symptom in 5% of patients and occurs at some point during the disease in 50% of patients. Prolonged spontaneous attacks of vertigo occur if a demyelinating plaque occurs at the root entry zone of the vestibular nerve or nucleus, and this presents as an acute peripheral vestibular disorder, such as vestibular neuritis. [1] Cerebellar stroke: may be due to infarction or haemorrhage. It may present in a similar fashion to vestibular neuritis. Magnetic resonance imaging (MRI) demonstrates the infarction or haemorrhage. It is important that MRI be done early, as one third of people with cerebellar infarction will develop acute, potentially lethal posterior fossa oedema requiring emergency neurosurgical decompression. [10] Vertebrobasilar ischaemia (usually affecting the anterior inferior cerebellar artery): these patients present with episodic vertigo lasting 1 to 15 minutes, with diplopia, dysarthria, ataxia, drop attack, and clumsiness of the extremities. days. Hereditary ataxias: a heterogeneous group of inherited genetic disorders. The most common autosomal recessive ataxia is Friedreich's ataxia, usually presenting with symptoms before 20 years of age. [1] The familial episodic ataxias are rare. Benign intracranial hypertension (pseudotumor cerebri): characterised by raised intracranial pressure that is not caused by a mass lesion (e.g., a tumour); associated with headache and transient poor vision. These patients are often obese and complain of clumsiness, imbalance, and dizziness rather than true vertigo. Some patients present with bilateral 6th nerve palsy or tinnitus. This may be associated with hypervitaminosis A. [11] Normal pressure hydrocephalus: associated with normal intracranial pressure and enlarged ventricles (hydrocephalus). Patients present with ataxia, urinary incontinence, and cognitive dysfunction. The diagnosis may be difficult to establish. [11] Wallenberg's syndrome: lateral medullary infarction, caused by occlusion of the ipsilateral vertebral artery that supplies the posterior inferior cerebellar artery and thereby causes prolonged vertigo lasting several

Mal de debarquement syndrome: thought to be due to a conflict between the sensory inputs from the visual, vestibular, and somatosensory systems and the central vestibular nuclei, cerebellum, and parietal cortex. It refers to the complaints of swinging, swaying, unsteadiness, and disequilibrium after exposure to motion. There may be a history of a long voyage, air travel, or space flight.

Paraneoplastic cerebellar degeneration: a rare complication of cancer of the ovary, breast, or lung, or of Hodgkin's lymphoma. Autoantibodies are thought to be directed against Purkinje cells. The anti-Yo antibody can present years before tumour detection. Anti-Tr antibody is associated with Hodgkin's lymphoma.

Cardiovascular
Syncope: defined as a sudden transient loss of consciousness with simultaneous diminution of postural tone, followed by spontaneous recovery. [12] The differential diagnosis includes vasovagal attacks, orthostatic hypotension, and medication-related and neurological causes, such as transient ischaemic attacks, cardiopulmonary disease, and arrhythmias. Presyncope: refers to lightheadedness without an illusion of movement and occurs prior to fainting or losing consciousness. It is a more common occurrence than syncope and is a prodromal symptom of fainting or near-fainting. Patients present with generalised weakness, giddiness, headache, blurred vision, and diaphoresis. There may also be paraesthesia, nausea, and vomiting prior to losing consciousness. The mechanism is almost always a reduction in blood supply to the brain. The symptoms may be spontaneous, positional, or associated with various triggers, depending on the cause. [1] [13] Orthostatic (or postural) hypotension: one of the most common causes of syncope and can be attributed to impaired peripheral vasoconstriction or a reduction in intravascular volume. It is defined by the American Autonomic Society as a decrease in systolic blood pressure (BP) of at least 20 mmHg or a decrease in diastolic BP of at least 10 mmHg within 3 minutes of standing. [14] This may occur in hypotensive patients or those on antihypertensive medication. Patients complain of dizziness on standing. [12] Autonomic dysregulation: patients present with exertional dizziness. Provocative activities include standing upright for prolonged periods, swimming, or running. Patients complain of feeling "spacey" or "foggy" during exertion without vertigo. Tilt-table testing may provoke symptoms. [15] [16]

Psychological
Psychophysiological dizziness (mixed physiological and psychogenic aetiology): may occur spontaneously or after a labyrinthine disorder. Patients complain of a variety of symptoms, such as rocking, floating, or swimming sensations. The symptoms may worsen with stress or fatigue. [1] Psychogenic dizziness: panic disorder with agoraphobia, personality disorders, or generalised anxiety is often present in patients complaining of dizziness. If the dizziness is psychogenic, patients may demonstrate inappropriate or excessive anxiety or fear. Phobic postural vertigo is characterised by dizziness in standing and walking despite normal clinical balance tests. Patients may demonstrate anxiety reactions and avoidance behaviour to specific stimuli. [17]

Metabolic
Diabetes mellitus: dizziness may be associated with episodes of hypoglycaemia. Also, diabetic patients with peripheral neuropathy may have more difficulty in recovering from a peripheral vestibular disorder. [18] Hypothyroidism: the prevalence of hypothyroidism has been found to be higher in patients diagnosed with Meniere's disease compared with a control group. [19]

Autoimmune
Systemic lupus erythematosus: patients may complain of vertigo or hearing loss and may have abnormal nystagmography. [20] Rheumatoid arthritis: patients are more likely to perceive themselves as having hearing loss, even with normal audiometry.[C Evidence] Cogan's syndrome: an inflammatory disorder resulting in interstitial keratitis and audiovestibular dysfunction. The pathology involves plasma cell and lymphocyte infiltration of the spiral ligament, endolymphatic hydrops, and degenerative disease of the organ of Corti. There is also demyelination of the 8th cranial nerve and inner ear osteogenesis. [21] Wegener's granulomatosis (granulomatosis with polyangitis): characterised by granulomatous lesions of the upper respiratory tract, necrotising vasculitis, and glomerulonephritis. [22] Behcet's disease: a generalised systemic relapsing vasculitis of the arteries and veins of unknown aetiology. [23]

Medication- or drug-related
Ototoxic drugs: aminoglycoside antibiotics such as gentamicin and neomycin are ototoxic. [24] [25] Ototoxicity has been described for topical as well as parenteral use. These drugs are vestibulotoxic and cochleotoxic. They may result in vertigo without causing hearing loss. Toxicity with parenteral use is related to the total dose administered. The risk factors are age >60 years, high serum drug levels, previous sensorineural hearing loss, concomitant renal impairment, attendant noise exposure, duration of therapy >10 days, and simultaneous administration of other ototoxic agents, such as loop diuretics or aspirin. Some patients have a genetic predisposition that makes them susceptible to ototoxicity secondary to aminoglycoside exposure. This is due to a mutation of the mitochondrial DNA m.1555A>G. This mutation accounts for 33% to 59% of aminoglycoside ototoxicity. [26] Chemotherapeutic drugs such as cisplatin are also ototoxic. [27] Cisplatin is widely used in various softtissue neoplasms. It causes sensorineural hearing loss and tinnitus. The severity of the sensorineural hearing loss is related to the magnitude of the cumulative dose. Alcohol: ingestion may cause patients to report feeling "high", dizzy, and intoxicated. [28] Other drugs: antihypertensive medication, anaesthetic medication, antiarrhythmic medication, drugs of abuse and various other drugs may cause patients to feel dizzy. Antihypertensive drugs may be associated with orthostatic hypotension. [12] Second-generation antiepileptic drugs such as oxcarbamazepine and topiramate at standard doses increase the risk of imbalance. This effect is not found at standard doses with gabapentin or levetiracetam. [29]

Traumatic or surgical
Post-traumatic vertigo: generally occurs as a result of blunt head trauma, such as a fall, an assault, or a motor vehicle accident. Patients may present with symptoms of a traumatic perilymphatic fistula or posttraumatic Meniere's disease. Patients may complain of vertigo, disequilibrium, tinnitus, pressure, headache, and diplopia. [30] Electronystagmography and caloric testing may demonstrate abnormalities. Computed tomography (CT) scans may demonstrate temporal bone fractures. MRI scans may demonstrate evidence of fluid in the middle ear or other abnormalities. Post-surgery: dizziness may be a complication of middle-ear surgery such as stapedectomy. Patients may complain of vertigo, which occurs because of a stapedectomy prosthesis that is too long or because of a perilymphatic fistula at the oval window. [31] Vertigo and balance disturbance may also occur after cochlear implantation and may be an immediate transient short-lived vertigo or episodic vertigo of delayed onset. [32] Patients with pre-implantation dizziness, those of an older age group (>59 years), and those with lateonset hearing loss (after the age of 26 years) are more likely to suffer post-operative dizziness. [32] Some studies suggest that vestibular disturbance following unilateral cochlear implantation is rare when measured by the dizziness handicap inventory, alternative bithermal caloric irrigations, or dynamic platform posturography. [33]

Infectious
Lyme disease: caused by tick-borne spirochete Borrelia burgdorferi, and other Borreliaspecies. Syphilis: congenital syphilis may present with sudden, profound bilateral hearing loss. Secondary syphilis may present with bilateral sensorineural hearing loss or vertigo. Patients with otosyphilis often present with vertigo. Late neurosyphilis may present with hearing loss, fluctuating hearing, or vestibular symptoms. [21] Cytomegalovirus (CMV): in-utero exposure may cause profound hearing and vestibular loss if the pregnant woman is exposed to the virus for the first time. [21] Up to 10% of children whose mothers were exposed to CMV for the first time during pregnancy may have sequelae of the disease. Some babies are born with severe hearing loss; other children may present with hearing loss at an older age. [34] Patients with previous exposure to CMV may experience virus reactivation in times of stress, leading to elevation of immunoglobulin (Ig)M and IgG titres. Herpes simplex virus 1 (HSV-1): herpes virus infection has been linked to sensorineural hearing loss. The virus may persist in the latent state in nerve cell bodies and ganglia. Audiovestibular symptoms may be caused by reactivation of latent infection. [21]Audiovestibular pathology of HSV-1 infection includes inflammatory neuritis, degeneration of the stria vascularis, and destruction of the organ of Corti with loosening of the tectorial membrane. HIV: can cause a polyneuropathy and CNS changes, which may result in dizziness and ataxia. [21]

Urgent considerations
See Differential Diagnosis for more details

Cerebellar stroke

Most vertigo causes are peripheral and non-life-threatening. However, those few vascular CNS causes are emergencies that should not be overlooked. Cerebellar stroke (cerebellar infarction or haemorrhage) may present in a similar fashion to vestibular neuritis, with sudden intense vertigo, nausea, and vomiting. Nystagmus is present and may be bilateral or vertical (suggesting a central cause of the vertigo). The patient may have other neurological signs, such as limb ataxia and impaired gait. Patients with cerebellar stroke usually cannot stand without support, even with the eyes open, whereas a patient with acute vestibular neuritis or labyrinthitis is usually able to do so. The head-impulse test is negative (no saccadic adjustment of the eyes on sudden head twisting), ruling out acute vestibular neuritis or labyrinthitis. Recent studies have suggested that this test should be combined with other tests of oculomotor function, including an examination of nystagmus and test of skew. [35] [36] Nystagmus, which changes direction on eccentric gaze, is a predictor of central pathology. Skew deviation is vertical ocular misalignment resulting from a right-left imbalance of vestibular tone (neural firing), such as otolithic inputs to the oculomotor system. This can be shown during an alternate cover test. Skew has been identified as a central sign in patients with posterior fossa pathology. These 3 tests identify stoke with a high degree of sensitivity and specificity in patients with acute vestibular symptoms, and they may rule out stroke more effectively than early diffusion-weighted MRI. MRI demonstrates the infarction or haemorrhage. It is important that an MRI is done early, as one third of these patients will develop acute, potentially lethal posterior fossa oedema, requiring emergency neurosurgical decompression. [10] Urgent MRI should be requested in all patients with acute vertigo who have significant risk factors for a cerebellar stroke, such as hypertension, diabetes mellitus, smoking, and cardiovascular disease, because it is possible that central signs on examination may not present. [37] Close neurological observation is important, as neurosurgical intervention may be required. [38]

Cardiovascular disease
Dizziness with syncope and chest pain may be related to cardiopulmonary disease such as myocardial ischaemia (spasm or infarction), obstructive (aortic or mitral stenosis) hypertrophic cardiomyopathy, pulmonary embolism, or hypertension. It is important to consider a history of associated chest pain, exertional syncope, and dyspnoea. [12] Urgent treatment may be required (e.g., aspirin, emergency revascularisation in some cases of acute coronary syndrome, anticoagulation, thrombolysis, or surgery for pulmonary embolism).

Vestibular neuritis and labyrinthitis

It is important to consider the diagnosis of vestibular neuritis and labyrinthitis, not because these conditions are life-threatening but because there may be long-term functional impairment if a correct early diagnosis is not made. Early treatment with corticosteroids has been shown to accelerate recovery of vestibular function in patients with vestibular neuritis. [37] Treatment may also be considered in people with labyrinthitis. Corticosteroid therapy within 3 days of onset of symptoms in people with vestibular neuritis may shorten the attack. Corticosteroids may or may not influence the long-term outcome. More serious conditions may also be mistakenly diagnosed as viral neuritis or labyrinthitis due to similar presenting symptoms. It is important to recognise that any patient presenting with unilateral or asymmetrical

sensorineural hearing loss (as may occur with labyrinthitis) needs to be investigated with MRI of the brain and internal auditory meatus to rule out a posterior fossa tumour (e.g., acoustic neuroma). [39]

Red flags
Meniere's disease Vestibular neuritis Syncope or presyncope Labyrinthitis Cholesteatoma Posterior fossa tumour Multiple sclerosis Cerebellar stroke Vertebrobasilar insufficiency Wallenberg's syndrome Paraneoplastic cerebellar degeneration Lyme disease Syphilis HIV

Step-by-step diagnostic approach

The clinical history and examination are most important in arriving at a differential diagnosis for each patient. The history should be detailed with regard to the patient's dizziness, and the examination should include otoscopy, CNS examination, and specific tests depending on the patient's presentation. [40]

History: characteristics of the current episode

The most important features in the patient's history of current complaint are as follows. Differentiating between dizziness and vertigo
Vertigo is a spinning or rotatory sensation of the patient or his or her surroundings, and is often in keeping with a vestibular event. Dizziness or unsteadiness is a more generalised term and may not indicate vestibular pathology. Patients who feel faint (presyncope) or actually have had syncopal attacks are more likely to have a cardiovascular problem such as orthostatic hypotension, cardiac ischaemia, or arrhythmia. [41] [12] However, a systematic review has shown that 63% of patients with cardiovascular causes of dizziness also report vertigo

and that, in 37%, vertigo is the only type of dizziness described. [42] Syncope is defined as a sudden transient loss of consciousness with simultaneous diminution of postural tone, followed by spontaneous recovery. [12] It has also been recently described as a transient loss of consciousness due to transient global cerebral hypoperfusion characterised by rapid onset, short duration, and spontaneous complete recovery. [43] Patients with presyncope may have generalised weakness, giddiness, headache, blurred vision, and diaphoresis. There may also be paraesthesia, nausea, and vomiting prior to losing consciousness. The mechanism is almost always a reduction in blood supply to the brain. The symptoms may be spontaneous, positional, or associated with various triggers, depending on the cause. [1] [13]

Determining whether the vertigo is better with the eyes open or closed
Patients who describe horizontal or rotational vertigo that decreases with visual fixation are more likely to have a vestibular complaint. Vertigo that does not lessen with visual fixation is more likely to be central in origin. [41]

Determining the duration of the vertigo

Vertigo lasting seconds and induced by positional change such as rolling over in bed is likely to be due to benign positional paroxysmal vertigo (BPPV). Vertigo lasting seconds and induced by loud sounds or coughing may be due to semicircular canal dehiscence. Vertigo lasting seconds with a history of trauma may be secondary to a perilymphatic fistula. [44] Vertigo lasting minutes to hours is suggestive of migraine, Meniere's disease, or cardiovascular disease such as a transient ischaemic attack. Vertigo lasting hours-to-days is suggestive of labyrinthitis, vestibular neuritis, central pathology such as multiple sclerosis or a stroke, or an anxiety disorder. [44]

Checking for positional triggers

Vertigo associated with BPPV occurs on head movement (e.g., rolling over in bed, bending down, or looking up quickly) and lasts seconds. Uncompensated unilateral vestibular loss may cause unsteadiness on head movement. Both are relieved by keeping the head still. Dizziness on getting up quickly may be associated with orthostatic hypotension and presyncope. [15] There may also be a history of antihypertensive medication use or a history of cardiac disease such as cardiac arrhythmia or cardiac failure. [12] Mild attacks of vertebrobasilar insufficiency may be associated with orthostatic hypotension. People with autonomic dysregulation present with dizziness (but not true vertigo) on standing upright for prolonged periods, swimming, or running.

Asking about the presence of other otological symptoms, such as tinnitus or hearing loss
Meniere's disease is associated with low-frequency hearing loss and tinnitus, both of which may fluctuate, as well as aural fullness. [45] The vertigo is frequently associated with nausea and vomiting. The

American Academy of Otolaryngology-Head and Neck Surgery has produced diagnostic guidelines. [46] A definite diagnosis is made on the basis of: [45] o o fullness. Labyrinthitis results in sudden hearing loss and/or tinnitus with acute vertigo lasting hours, and nausea and vomiting. [6] It is important to try to differentiate between labyrinthitis and vestibular neuritis. Vestibular neuritis is more common than labyrinthitis and presents with recurrent attacks of disabling vertigo, with no associated hearing loss or tinnitus. loss. The presentation of posterior fossa tumours is typically with unilateral hearing loss, and imbalance rather than true vertigo. [39] Acute onset of dizziness may be associated with a bacterial otitis media and labyrinthitis. [6]In this case there may be fever, irritability, and otalgia. Patients who have had previous mastoid surgery with a mastoid cavity are prone to dizziness with an ear infection. Other middle-ear diseases such as cholesteatoma may be associated with vertigo. Typically, there is a malodorous ear discharge and hearing loss with or without tinnitus. There may be an associated hearing loss in people with systemic lupus erythematosus or multiple sclerosis. People with rheumatoid arthritis are more likely to perceive themselves as having hearing loss, even with normal audiometry.[C Evidence] Otological manifestations of Wegener's granulomatosis (granulomatosis with polyangitis) include vertigo, serous otitis media, chronic otitis media, sensorineural hearing loss, and facial nerve palsy. [47] Hearing loss may also occur following syphilis infection, HSV-1 infection, and in-utero exposure to CMV infection, as well as with perilymphatic fistula, Mondini's dysplasia, Cogan's syndrome, and exposure to ototoxic drugs or medications. Superior semi-circular canal dehiscence is characterised by episodes of vertigo associated with loud sound and/or altered middle-ear pressure, hyperacusis to bone-conducted sounds, and a conductive hearing At least 2 attacks of spontaneous rotational vertigo, lasting at least 20 minutes Audiometric confirmation of sensorineural hearing loss, tinnitus, and/or a perception of aural

Determining how the episodes began

Patients with a preceding upper respiratory infection may have viral neuritis or labyrinthitis.[41] Patients with a history of sea, air, or train travel prior to the onset of symptoms and with symptoms occurring on disembarking may have mal de debarquement (MDD) syndrome.[48] Patients with MDD complain of swinging, swaying, unsteadiness, and disequilibrium after exposure to motion. The symptoms commonly last for only a few hours, but some patients may continue to experience symptoms for months or even years. The symptoms differ from motion sickness that occurs after disembarking and are not associated with nausea or vomiting. [48]

Patients with a history of trauma or barotraumas (e.g., scuba divers or pilots) may have a perilymphatic fistula. [44]

Asking about other more general symptoms associated with the vertigo
It is important to consider a history of associated chest pain, exertional syncope, and dyspnoea that may be related to a cardiovascular aetiology. [12] Vestibular migraine may be associated with aura, visual disturbance, photophobia, or phonophobia, with or without headaches. [41] Patients have varied symptoms, including true episodic vertigo, movement-provoked disequilibrium, lightheadedness, and symptoms similar to BPPV. [9] They may also present with symptoms similar to Meniere's disease. Nausea is often associated with peripheral vestibular disorders as a part of the autonomic response. Neurological symptoms such as gait disturbance, limb weakness, or dysarthria may indicate neurological pathology, such as cerebellar infarction [10] or cerebellar pathology. Patients with vertebrobasilar insufficiency present with episodic vertigo lasting 1 to 15 minutes, with diplopia, dysarthria, ataxia, drop attack, and clumsiness of the extremities. Patients with normal pressure hydrocephalus present with ataxia, urinary incontinence, and cognitive dysfunction. The diagnosis may be difficult to establish. [11] Patients with benign intracranial hypertension are often obese and complain of clumsiness, imbalance, and dizziness rather than true vertigo; benign intracranial hypertension is associated with headache and transient poor vision. Some patients present with bilateral 6th nerve palsy or tinnitus. Patients with Cogan's syndrome and associated audiovestibular dysfunction present with ocular and audiovestibular symptoms including photophobia, ocular discomfort, ocular redness, fluctuating sensorineural hearing loss, and imbalance or vertigo. [49] Patients with Wegener's granulomatosis (granulomatosis with polyangitis) may present with limited forms of the disease, usually with head and neck involvement. Otological manifestations include serous otitis media, chronic otitis media, sensorineural hearing loss, and facial nerve palsy. [47] Audiovestibular manifestations of Behcet's disease include hearing impairment, tinnitus, and dizziness, but it is also characterised by recurrent genital and oral ulceration and uveitis.

Asking about psychiatric symptoms

Panic disorder with agoraphobia, personality disorders, or generalised anxiety is often present in patients complaining of dizziness. If the dizziness is psychogenic, patients may describe symptoms of excessive anxiety or fear. A hospital and anxiety depression scale of >8 is diagnostic. [50] Phobic postural vertigo is characterised by dizziness on standing and walking, despite normal clinical balance tests.

Patients may describe avoidance behaviour to specific stimuli. [17] Patients with psychophysiological dizziness may describe an initial labyrinthine disorder with persisting symptoms.

History: identification of cause

History of trauma or surgery
Dizziness may be a complication of middle-ear surgery such as stapedectomy. Patients may complain of vertigo, which occurs because of a stapedectomy prosthesis that is too long or because of a perilymphatic fistula at the oval window. [31] Vertigo and balance disturbance may also occur after cochlear implantation and may be an immediate transient short-lived vertigo or episodic vertigo of delayed onset. [32] A perilymphatic fistula may occur after stapes surgery or head trauma or in divers. It is characterised by paroxysmal vertigo, imbalance, and a sensorineural hearing loss with or without tinnitus. [8] Post-traumatic vertigo generally occurs as a result of blunt head trauma such as a fall, an assault, or a motor vehicle accident. Presenting symptoms may be of a traumatic perilymphatic fistula or post-traumatic Meniere's disease. Patients may complain of vertigo, disequilibrium, tinnitus, pressure, headache, and diplopia. [30] Many patients with superior semi-circular canal dehiscence present after head trauma, and their dizziness may initially be thought to be post-traumatic vertigo, labyrinthine concussion, or perilymphatic fistula.

History of other medical illnesses

Diabetes mellitus may be associated with attacks of dizziness associated with hypoglycaemic episodes. [18] Hypothyroidism, [19] rheumatoid arthritis, [51] or systemic lupus erythematosus [20] may also be associated with dizziness. Dizziness occurs as an initial symptom in 5% of people with multiple sclerosis and occurs at some point during the disease in 50% of patients. Patients may present with a variety of neurological findings, such as nystagmus, ataxia, and cranial nerve palsies. [1] Patients with a history of migraine are more likely to have migraine-associated vertigo. Migraine or Meniere attacks may be clustered.

Family history of illness

There may be a family history of migraine. There may be a family history of hereditary ataxias. Most commonly, Friedreich's ataxia presents with symptoms of ataxia, vertigo, nausea and vomiting, dysarthria, and nystagmus before the age of 20 years. [1]

Known or contact with infectious disease

A patient with dizziness associated with Lyme disease has a history of outdoor exposure in areas with high tick populations. Symptoms include rash, headache, neck pain and stiffness, sore throat, dizziness, otalgia, tinnitus, facial and motor dysfunction, hearing loss, and facial palsy. [52]

Congenital syphilis may result in deafness. Secondary syphilis may present with bilateral sensorineural hearing loss or vertigo. Patients with otosyphilis often present with vertigo. Late neurosyphilis may present with hearing loss, fluctuating hearing, or vestibular symptoms. [21]

Exposure in utero to CMV for the first time during pregnancy is associated with profound hearing and vestibular loss in the infant. [21] Audiovestibular symptoms (including sensorineural hearing loss) may be caused by reactivation of latent HSV-1 infection and may be preceded by herpetic skin lesions. [21] People with HIV infection may also describe onset of dizziness and difficulty with balance.[21]

Medication and drug history

There may be a history of medication or drug use associated with ototoxicity. Examples include aminoglycoside antibiotics such as gentamicin and neomycin (particularly if these have been administered concomitantly with loop diuretics or aspirin), chemotherapeutic agents (e.g., cisplatin), antihypertensives, anaesthetics, or antiarrhythmics. There may also be a history of associated acute intoxication with alcohol.

Risk factors for cardiovascular disease or stroke

Assessment of a patient with vertigo should include assessment for risk factors for stroke, such as hypertension, hyperlipidaemia, diabetes mellitus, smoking, or heart disease. [1] A cardiovascular cause, vertebrobasilar insufficiency, Wallenberg's syndrome, and cerebellar stroke are all more likely if there are risk factors present. Patients with cerebellar stroke may present in a similar fashion to vestibular neuritis, with sudden intense vertigo, nausea, and vomiting. Urgent MRI should be considered in all patients with acute vertigo who have significant risk factors for a cerebellar stroke such as hypertension, diabetes mellitus, smoking, and cardiovascular disease, because it is possible that central signs on examination may not present. [37]

History of neoplastic disease

Paraneoplastic cerebellar degeneration is a rare complication of cancer of the ovary, breast, or lung, or of Hodgkin's lymphoma. Patients present with dizziness, nausea and vomiting, gait instability, diplopia, nystagmus, gait and appendicular ataxia, dysarthria, and dysphagia. [1] [53]

Physical examination: ear

Ear examination

Acute onset of dizziness may be associated with a bacterial otitis media with labyrinthitis. [6]Acute otitis media does not usually result in dizziness, but where there is complicating labyrinthitis it may occur. The tympanic membrane in acute otitis media is erythematous, opaque, and bulging. View image

Other middle-ear diseases such as cholesteatoma may be associated with vertigo. Otoscopy reveals crust or keratin in the attic (upper part of the middle ear), pars flaccida, or pars tensa (usually posterior superior aspect), with or without perforation of the tympanic membrane. View image

Patients who have had previous mastoid surgery with a mastoid cavity are prone to dizziness with an ear infection or when swimming in cold water.

There may be evidence of fluid or blood in the middle ear and/or cerebrospinal fluid (CSF) otorrhoea if the dizziness is related to trauma.

People with Wegener's granulomatosis (granulomatosis with polyangitis) may have signs of serous otitis media or chronic otitis media.

The fistula test

ear. A positive result of induced dizziness and nystagmus occurs with superior semi-circular canal dehiscence, post-surgical dizziness, or perilymphatic fistula. Fistula test may be positive in people with cholesteatoma. A positive fistula test provides support for doing a temporal bone CT. Performed by applying pressure on the tragus to occlude the ear or by pneumatic otoscopy (exerting pressure on each ear canal with a rubber bulb attached to an auriscope), thereby putting pressure on the middle

Physical examination: eye

Observation for nystagmus
The presence of nystagmus may indicate peripheral or central pathology. A central vestibular lesion produces vertical, bidirectional, or pure rotatory nystagmus. Abnormal saccades and smooth pursuit may also indicate central pathology. Observation of the eyes may lead to suspicion for other ophthalmological conditions, such as interstitial keratitis in Cogan's syndrome or uveitis in Behcet's disease.

Observation of eye movements

Ophthalmoplegia with palsies of cranial nerves III, IV, or VI may occur with multiple sclerosis or with an intracranial lesion. [1] Neurological signs such as diplopia, disconjugate gaze, Horner's syndrome, and gait ataxia are in keeping with a central lesion.

Examination of the eyes with Frenzel glasses

These glasses use +30 diopter lenses to blur the patient's vision, remove optical fixation, and uncover vestibular nystagmus. [10] [54] It may be possible to use an ophthalmoscope instead of the Frenzel glasses to blur vision. Infrared video goggles may be used instead of Frenzel glasses.

Examination of dynamic visual acuity

This tests the vestibulo-ocular reflex by observing the effect of head rotation on visual acuity (e.g., by reading the letters on a Snellen chart). [41] Abnormal results indicate a bilateral vestibular failure.

Physical exam: clinical balance tests

The head impulse test
Particularly useful to differentiate between acute vestibular neuritis and cerebellar stroke in patients with acute vertigo. [10] The examiner turns the patient's head as rapidly as possible 15 degrees to one side and observes the patient's ability to keep fixating on a distant target. With a peripheral vestibular lesion, a saccade occurs as the vestibulo-ocular reflex fails, the patient cannot keep focusing on the target, and a catch-up movement occurs. After a cerebellar stroke, no catch-up saccade occurs. The head-impulse test is negative (no saccadic adjustment of the eyes on sudden head twisting) in people with cerebellar stroke, ruling out acute vestibular neuritis or labyrinthitis.

The Dix-Hallpike test

This is useful in patients with a history suggestive of BPPV. The test is performed by sitting the patient upright on a bed; for the right side, the examiner stands on the patients right side, rotates the patients head 45 to the right, and then moves the patient, whose eyes are open, to the supine right-ear down position, and then extends the patients neck slightly so that the chin points slightly upwards. Patient's symptoms are noted and any nystagmus is observed. [3] [54] This manoeuvre is associated with strong subjective symptoms, and the patient may cry out.

Classically, peripheral nystagmus and symptoms are delayed by about 15 seconds, peak in 20 to 30 seconds, and then decay with complete resolution of the episode of vertigo. The test is repeated on the left with the examiner standing on the patients left side. The nystagmus fatigues on repeat testing. [55]

BPPV is typically due to posterior canal pathology. If the pathology affects the horizontal canal, the nystagmus may be more persistent and less fatigable.

When symptoms are due to central pathology, the test causes nystagmus that is not fatigable, is downbeating, and is associated with minimal vertigo.

The Dix-Hallpike test has been shown to have a positive predictive value of 83% and a negative predictive value of 52% for the diagnosis of BPPV. [56]

Supine roll test

If the Dix-Hallpike test is negative in a patient who has a history suggestive of BPPV, a supine roll test should be performed. [3] [4] This supine roll test is performed by positioning the patient supine with the head in the neutral position, then quickly rotating the head 90 to one side while the clinician observes the patients eyes for nystagmus. The head is returned to the face up position, allowing all dizziness and nystagmus to subside; the head is then turned rapidly to the opposite side. [3] [57]

Physical examination: CNS

Examination of the other cranial nerves
Other cranial nerve palsies such as facial weakness or numbness may occur with cerebellopontine angle tumours. Tongue weakness with limb weakness may be a feature of a cerebral stroke. Facial nerve palsy may occur with Wegener's granulomatosis (granulomatosis with polyangitis).

Neurological examination
Examination of cerebellar function is usually tested with the finger-to-nose test and rapid alternating hand movements. [54] This may be abnormal in cerebellar lesions. Gait should be checked for any disturbance, along with examination for limb weakness or dysarthria. These may indicate a neurological pathology such as cerebellar infarction or other cerebellar pathology. [10] Wallenberg's syndrome (lateral medullary infarction caused by occlusion of the ipsilateral vertebral artery that supplies the posterior inferior cerebellar artery) causes prolonged vertigo, abnormal eye movements, ipsilateral Horner's syndrome, ipsilateral limb ataxia, and loss of pain and temperature sensation of the ipsilateral face and contralateral trunk. [13]

Patients with Freidreich's ataxia demonstrate cerebellar ataxia, sensory neuropathy with areflexia, dysarthria, and optic atrophy. The rare familial episodic ataxias may demonstrate ataxia, dysarthria, and nystagmus. [1]

Various neurological signs may be present in people with multiple sclerosis (e.g., altered gait, weakness, nystagmus, cranial nerve palsies).

Signs of peripheral neuropathy may occur in patients with diabetes mellitus (e.g., numbness and presence of painless injuries).

Romberg and Unterberger (Fukuda) tests

Provides information about the patient's balance with the eyes closed. The Romberg test involves asking the patient to attempt to maintain a standing position with the feet together, eyes closed, and arms outstretched. The Unterberg test involves asking the patient to perform stationary stepping with eyes closed for up to 1 minute. A tendency to veer towards the affected side occurs after a unilateral vestibular loss. These are non-specific tests that can be abnormal in peripheral or central lesions. [41] Ataxia due to a central pathology is usually more severe. [58] Patients with cerebellar infarction usually cannot stand without support, even with the eyes open, whereas a patient with acute vestibular neuritis or labyrinthitis can. Bizarre changes (e.g., "wooden soldier" or "scissor gait") may occur in psychogenic lesions.

Physical examination: cardiovascular system and general examination

Cardiovascular examination
It is important to check for an irregular pulse or carotid bruits, especially in older patients or those with risk factors such as hypertension. [41] Lying and standing BP should be checked, as this is useful in patients with postural symptoms. It may demonstrate a fall in systolic or diastolic BP in keeping with orthostatic hypotension. [14] This has been defined by the American Autonomic Society as a decrease in systolic BP of at least 20 mmHg or a decrease in diastolic BP of at least 10 mmHg within 3 minutes of standing. [14]

General examination may reveal evidence of other conditions (e.g., oral ulcers with Behcet's disease; joint disease with rheumatoid arthritis; evidence of multi-system involvement with systemic lupus erythematosus; and rashes with Lyme disease, HIV, or syphilis).

Investigations: pure-tone audiogram

Demonstrates any associated hearing loss.

A unilateral sensorineural hearing loss may occur in labyrinthitis and Meniere's disease (low frequency). Unilateral or asymmetrical sensorineural hearing loss should prompt investigation for a posterior fossa tumour (e.g., acoustic neuroma). [39]

Investigations: imaging of the head

CT scan of the petrous temporal bones
A high-resolution thin-cut CT scan is useful in patients suspected of having superior semi-circular canal dehiscence (SSCD). [7] SSCD is a clinical and not just a radiographical diagnosis, but the results of the CT scan help to confirm a suspected diagnosis. CT scanning is also useful in the diagnosis of middle ear or mastoid disease. It should be performed if temporal bone fracture is suspected. CT of the petrous temporal bones may also be helpful to confirm cholesteatoma.

MRI of internal auditory meatus and brain

Should be done in patients suspected of having a posterior fossa tumour or cerebellar stroke. [10] [39] [59] Urgent MRI should be requested in all patients presenting with acute vertigo who have significant risk factors for a cerebellar stroke such as hypertension, diabetes mellitus, smoking, and cardiovascular disease. It is important that MRI be done early, as one third of patients with cerebellar infarction will develop acute, potentially lethal posterior fossa oedema requiring emergency neurosurgical decompression. [10] Recent advances in MRI techniques enable visualisation of endolymphatic hydrops. [60] Demonstrates the space-occupying lesion in the presence of a posterior fossa tumour. Demyelinating lesions may be seen on MRI in people with multiple sclerosis. Also performed if there is a history of head injury with abnormal neurology.

MRI angiography can be used to find vascular causes in appropriate patients. It may be performed to help to confirm suspected vertebrobasilar insufficiency (demonstrating occlusion of the cerebellar arteries) or Wallenberg's syndrome (demonstrating occlusion of the ipsilateral vertebral artery).

Investigations: vestibular function tests

Numerous tests are available, such as electronystagmography (ENG) and caloric testing.

The tests can be useful in cases of diagnostic uncertainty to demonstrate a unilateral or bilateral vestibular loss.

Typically, a directional preponderance with nystagmus greater in one direction or the other of 26% to 30% indicates significant asymmetry, and a canal paresis (reduced function) of 22% to 25% indicates a unilateral vestibular loss. [41]

Computerised dynamic post-urography testing: utilises a computerised controlled platform and visual booth to assess sensory and motor components of balance. [54] The test results in 6 abnormal sensory patterns useful for clinical diagnosis and rehabilitation.

Rotatory chair testing: an adjunctive balance test that may be used if ENG is abnormal. Electrocochleography: may be useful in the diagnosis of Meniere's disease. The trans-tympanic test is a more invasive type of electrocochleography and is a more sensitive test than extra-tympanic electrocochleography.

Acoustic reflex assessment: involves exposing the patient to loud noise to observe the muscle that causes movement of the stapes to protect the ear. It is a secondary assessment of stapes function and would be abnormal in people with otosclerosis and normal in people with superior semi-circular canal dehiscence.

Vestibular evoked myogenic potential: indicated only when superior semi-circular canal dehiscence is suspected. In this case, increased amplitude may be demonstrated. This test is uncommonly performed and may not be widely available.

Investigations: cardiovascular
ECG
May be done in patients with a history of syncope to look for ventricular tachycardia or bradycardia. [12] [43]

Echocardiography
Useful for patients with pre-syncope or syncopal episodes where cardiac pathology is suspected.

Cardiac monitoring
Indicated in patients with pre-syncope or syncopal episodes that are suspected to be associated with cardiac arrhythmias.

Tilt-table testing
Done in cases where orthostatic hypotension is suspected or there is a possibility of autonomic dysregulation. [12] [43] Symptoms are provoked on testing.

Further investigations in specific circumstances

Blood tests performed in specific circumstances
Including antinuclear antibodies, double-stranded DNA, Smith antigen (if systemic lupus erythematosus is suspected); serum thyroid-stimulating hormone (TSH) and serum free T4 (if hypothyroidism is suspected); rheumatoid factor (for new diagnosis of rheumatoid arthritis); antineutrophil cytoplasmic antibody and biopsy of lesions for histology (if Wegener's granulomatosis (granulomatosis with polyangitis) is suspected); treponemal antibody tests (if syphilis infection is suspected); CMV viral titres (in suspected CMV infection); type-specific HSV serological assay (for diagnosis of HSV-1); HIV test if this diagnosis is suspected. Blood glucose monitoring and HbA1c in patients with diabetes mellitus who have dizzy episodes possibly related to hypoglycaemia. A lower than expected HbA1c is suggestive but not diagnostic of hypoglycaemic episodes. Self-monitored blood glucose levels are required for confirmation. Serum drug levels, a urine drug toxicity screen, and blood drug toxicity screen may be appropriate if the symptoms are thought to be medication- or drug-related. A blood alcohol level, gamma glutamyl transpeptidase (gamma-GT), aspartate aminotransferase (AST), and alanine aminotransferase (ALT) may be performed if dizziness associated with acute alcohol intake is suspected. TSH and free T4 will be tested in children and adults with Mondini's dysplasia diagnosed on CT scan with co-existent thyroid mass on clinical examination.

Slit-lamp ophthalmoscopic examination

Necessary if the diagnosis of Cogan's syndrome is considered.

Genetic testing
Performed if hereditary ataxia is suspected.

Exploratory tympanotomy
May be done to investigate the cause of post-surgical dizziness or when there is a suspected diagnosis of perilymphatic fistula.

Lumbar puncture and measurement of CSF pressure

Required to diagnose benign intracranial hypertension and normal pressure hydrocephalus.

Cisternography
Performed to demonstrate the absence of obstruction of the cerebral aqueduct or of CSF outflow from the 4th ventricle in people with normal pressure hydrocephalus.

Differential diagnosis
Sort by: common/uncommon or category Commonhide all Benign positional paroxysmal vertigo see our comprehensive coverage of Benign paroxysmal positional vertigo

History
in bed or looking up, which lasts for seconds

Exam
vertigo, typically demonstrating nystagmus and symptoms that are delayed by about 15 seconds, peak in 20 to 30 seconds, and then decay with complete resolution of the episode of vertigo

1st test

none: the diagnosis is typically made by clinical diagnosis alone

vertigo on rolling over Dix-Hallpike test is diagnostic: peripheral benign positional paroxysmal

Meniere's disease see our comprehensive coverage of Meniere's disease

History
vertigo is frequently disabling, associated with nausea and vomiting; definite diagnosis requires a hx of at least 2 attacks of spontaneous rotational vertigo lasting at least 20 minutes, hearing loss, tinnitus, and/or a perception of aural fullness

Exam
normal

1st test

pure-tone audiogram:sensorineural hearing-loss pattern usually at low frequencies

Other tests

electronystagmogr

reduction in function

electrocochleograp

potential:summating

abnormal tone burst

Vestibular neuritis

MRI of internal aud brain: normalMore

History
acute onset of vertigo with nausea and vomiting, lasting days but without recur

Exam
acute episode: may be nystagmus to the affected side, head impulse test will be abnormal (due to loss of the vestibulonormal

1st test

pure-tone

audiogram: normal patternMore

hearing loss; single episodes frequently ocular reflex); between episodes of vertigo examination may be

Vestibular migraine see our comprehensive coverage of Migraine headache in adults

History
personal hx or FHx of migraine; vertigo with or without movement-provoked disequilibrium, lightheadedness, symptoms similar to benign positional paroxysmal vertigo, photophobia, phonophobia, or other auras, or symptoms similar to Meniere's disease

Exam
usually

1st test

pure-tone audiogram: normal pattern

Other tests

caloric testin

headaches; symptoms variable including true episodic vertigo, normal

weaknessMo

electronysta

rotatory cha

of observed n

Syncope or presyncope see our comprehensive coverage of Assessment of syncope

History
variable depending on specific cause

Exam
vasovagal attack: hypotensive during attack;

1st test

ECG: may demonstrate ventricular bradycardia

Other tests

ech

but may include generalised weakness, transient ischaemic attack: transient

stru

giddiness, headache, blurred vision, and neurological findings during attacks; diaphoresis; may be paraesthesia, nausea, and vomiting prior to loss of consciousness cardiopulmonary disease: altered cardiac rhythm, murmurs, evidence of cardiac failure

or tachycardiaMore

card

mon

dete

epis

tilt-t

evid

sym

Orthostatic hypotension see our comprehensive coverage of Orthostatic hypotension

History
dizziness on standing from a lying or sitting a history of antihypertensive medication use

Exam
drop in systolic BP by 20 mmHg standing from a lying position

1st test

none: diagnosis usually made clinically without further investigations

Oth

position, episodes are usually transient, may be or diastolic BP by 10 mmHg on

Diabetes mellitus see our comprehensive coverage of Overview of diabetes

History
most commonly occurs in people with a known hx of diabetes mellitus; often, dizziness may coincide with episodes of hypoglycaemia where patient feels unwell, clammy, generally weak; may be a preceding associated peripheral neuropathy (associated numbness in feet and legs and hx of painless injuries)

Exam
signs of peripheral neuropathy including numbness and presence

1st test

blood glucose monitoring: low during attacksMore

Ot

peripheral vestibular disorder and prolonged symptoms, particularly with of painless injuries

Hypothyroidism see our comprehensive coverage of Overview of thyroid dysfunction

History
hx of hypothyroidism; may have symptoms suggestive of Meniere's disease with unilateral hearing loss; vertigo lasting over 20 minutes and tinnitus; other symptoms of hypothyroidism, including constipation, weight gain, cold sensitivity, menstrual irregularity, and depression

Exam
may be normal; may be other signs of hypothyroidism such as thyroid swelling, dry skin, coarse hair, thick tongue, facial oedema, cold peripheries, and bradycardia

1st test

se

hy

ele

se

no

Rheumatoid arthritis see our comprehensive coverage of Rheumatoid arthritis

History
hx of rheumatoid arthritis, joint pain, morning stiffness, dizziness, and hearing loss

Exam
arthritic joints, joint swelling, and poor balance

1st test

rheumatoid factor: positive (70%), but may be negative

Other tests

pure-ton despite

Alcohol see our comprehensive coverage of Alcohol addiction

History

Exam

1st test

Other tests

acute intoxication: patients report feeling smell of alcohol on the breath, "high", dizzy, and intoxicated disorientation, abnormal gait

blood alcohol level: may be elevated

seru GT,

Drugs see our comprehensive coverage of Overview of substance abuse and overdose

History
hx of aminoglycoside antibiotics, cisplatin, or other drugs that may cause dizziness (e.g., medication, antiarrhythmic medication); hearing loss and tinnitus with aminoglycosides and cisplatin

Exam
may have signs of renal impairment with aminoglycosides and cisplatin or be may be associated with orthostatic hypotension

1st test

clinical examination: the diagnosis is often made clinically from the history and physical findings

antihypertensive medication, diuretics, anaesthetic normal; use of antihypertensive drugs

Uncommonhide all
Labyrinthitis see our comprehensive coverage of Labyrinthitis

History
acute onset of vertigo with nausea and vomiting lasting days; associated hearing loss be a preceding hx of acute otitis media

Exam
nystagmus is usually horizontal, and severity improves as the illness resolves; ear examination may demonstrate evidence of acute otitis media membrane); post-aural redness or swelling may occur if mastoiditis complicates the infection

1st test

pure-tone audiogram: unilateral sensorineural hearing-loss pattern; a conductive loss pattern may occur if acute otitis media is present

with or without tinnitus; may (bulging, erythematous, or opaque tympanic

Cholesteatoma see our comprehensive coverage of Cholesteatoma

History

Exam

1st test

Other tests

malodorous ear discharge and hearing loss with or without tinnitus; less altered taste, or facial weakness

otoscopy reveals crust or keratin in the attic (upper part of the middle ear), the pars flaccida, or the pars tensa (usually perforation of the tympanic membrane; fistula test may be positive

pure-tone audiogram: normal, conductive, or mixed conductive/sensorineural hearing-loss pattern

CT scan

bones: o

commonly vertigo, otalgia, posterior superior aspect), with or without

ossicular scutum;

cochlear

involvem

Superior semi-circular canal dehiscence

History
hx of episodes of vertigo associated with sound or pressure such as coughing, sneezing, straining, or sudden loud noise and hyperacusis; a feeling of the affected ear being blocked; may be preceding hx of trauma

Exam
upward and torsional nystagmus evoked by pressure such as the fistula test

1st test

pure-tone audiogram:conductive hearing-loss pattern

CT scan petrous temporal bones: bo

dehiscence of the superior semi-circula canal on the affected sideMore

Perilymphatic fistula

vestibular evoked myogenic potential: increased amplitudeMore

History

Exam

1st test

pure-tone audiogram:sensorineural hearingloss pattern

Other tes

may have a hx of surgery such as stapes surgery, head may have a positive trauma, or diving; paroxysmal vertigo, imbalance, and fistula test hearing loss with or without tinnitus

Mondini's dysplasia

History
children being investigated or with a hx of hearing loss

Exam
the condition is a radiological diagnosis; hearing loss; in some cases goitre may be detected

1st test

audiology: sensorineural hearingloss patternMore

Other tes

for sensorineural hearing loss examination may be normal apart from

Posterior fossa tumour see our comprehensive coverage of Overview of brain tumours

History
typically unilateral hearing loss, dizziness, or vertigo and tinnitus

Exam
spontaneous nystagmus may be present

1st test

pure-tone audiogram: unilateral sensorineural hearing-loss pattern

Other tests

electronystagmogr

abnormal optokinetic

MRI internal auditory meatus and brain: space-occupying lesion in cerebellopontine angle

Multiple sclerosis see our comprehensive coverage of Multiple sclerosis

History
(50%); prolonged spontaneous attacks of vertigo may be similar to altered gait

Exam
such as nystagmus, ataxia, and

1st test

pure-tone

vertigo as an initial symptom (5%) or at some point during their disease variety of neurological findings, vestibular neuritis; variety of symptoms such as dizziness, diplopia, and cranial nerve palsies

audiogram:sens loss pattern

MRI brain: dem demonstrated

Cerebellar stroke see our comprehensive coverage of Overview of stroke

History
nausea, and vomiting

Exam
cause), head impulse test is negative, patients usually cannot stand without support

1st test

sudden intense vertigo, nystagmus present and may be bilateral or vertical (suggesting a central

MRI brain: lesions demonst

cerebellar infarction or haem

Vertebrobasilar insufficiency see our comprehensive coverage of Transient ischaemic attack

History
drop attack, and clumsiness of the extremities; may have risk factors for stoke such as hypertension, hyperlipidaemia, diabetes, smoking, or heart disease

Exam

1st test

MRI brain angiogram: may be demonstrating areas of infarction;

episodic vertigo lasting 1-15 minutes, with diplopia, dysarthria, ataxia, usually normal

of the cerebellar arteries may be d angiography

Wallenberg's syndrome see our comprehensive coverage of Ischaemic stroke

History
double vision, abnormal balance, facial or limb numbness

Exam
abnormal eye movements; ipsilateral Horner's syndrome; ipsilateral limb ataxia; loss of pain and temperature sensation of the ipsilateral face and contralateral trunk

1st test

MRI brain angiogram:occl

ipsilateral vertebral artery ma demonstrated

Trauma see our comprehensive coverage of Assessment of traumatic brain injury

History
hx of head trauma (e.g., a fall, an vertigo, disequilibrium, tinnitus, pressure, headache, diplopia

Exam
evidence of fluid or blood in the bone fracture or abnormal neurological findings, CSF otorrhoea

1st test

CT scan petrous temporal bones: temporal bone fracture demonstrated

Other tests

electronys of affected

assault, or a motor vehicle accident), middle ear, evidence of a temporal

caloric tes

affected sid

Paraneoplastic cerebellar degeneration

MRI scan h

History
or hx of Hodgkin's lymphoma; dizziness, nausea and vomiting, gait instability, altered speech, and dysphagia

Exam
of pursuit, saccadic oscillations, and an ataxic gait with or without features of the associated cancer

1st test

MRI brain: evidence of cerebellar degenerationMore

Other te

hx of cancer of the ovary, breast, or lung, nystagmus, ocular dysmetria, abnormalities

CT scan brain: evidence of cerebellar degenerationMore

CT scan or MRI of body: tumour demonstrated

Hereditary ataxia see our comprehensive coverage of Assessment of ataxia

History
may have a positive FHx,

Exam
nystagmus, cerebellar ataxia,

1st test

MRI brain: mild to prominent cerebellar atrophy demonstrated

Other tests

electronystag

abnormal gait, vertigo with nausea sensory neuropathy with areflexia, and vomiting, altered speech, poor dysarthria, optic atrophy vision

impaired pursu

caloric test: re

genetic testing abnormality

Benign intracranial hypertension see our comprehensive coverage of Pseudotumor cerebri

History
often obese; headaches and transient episodes of poor vision; dizziness and tinnitus

Exam
papilloedema on fundoscopy; some have bilateral 6th nerve palsy

1st test

MRI brain: slit-like ventricles demonstrated

Other tests

lumbar

CSF pre

Normal pressure hydrocephalus see our comprehensive coverage of Normal pressure hydrocephalus

History
hx of abnormal balance, urinary

Exam
ataxic gait, cognitive

1st test

MRI brain: normal

Other tests

lumbar puncture and m

incontinence, and cognitive dysfunction dysfunction

pressure: normal CSF p

Mal de debarquement syndrome

cisternography: no bloc

CSF outflow from the 4th

History
swinging, swaying, unsteadiness, and disequilibrium after exposure to motion (e.g., long voyage, air travel, or space flight); symptoms may last for hours, months, or years; symptoms occur after disembarking; not associated with nausea or vomiting

Exam
usually normal

1st test

pure-tone audiogram: normal pattern

Other tests

electrony

Autonomic dysregulation

History
for prolonged periods, swimming, or running; patients complain of feeling "spacey" or "foggy" without vertigo during exertion

Exam

1st test

none: diagnosis usually made

dizziness on exertion; provocative activities include standing upright usually normal

clinically without further investigati

Psychophysiological dizziness

History
a variety of symptoms such as rocking, floating, or or fatigue

Exam
anxious, may be hyperventilating,

1st test

hospital anxiety and depr

swimming sensations; symptoms may worsen with stress normal clinical balance tests

scale: may be abnormally h

Psychogenic dizziness

History
dizziness on standing and walking; may demonstrate anxiety reactions and avoidance behaviour to specific stimuli; may be hx of panic disorder with agoraphobia, personality disorders, or generalised anxiety; inappropriate or excessive anxiety or fear

Exam
normal clinical balance tests

1st test

hospital anxiety

scale score:abno (>8)More

Systemic lupus erythematosus see our comprehensive coverage of Systemic lupus erythematosus

History
hx of systemic lupus

Exam
clinical features of systemic lupus

1st test

antinuclear antibodies, double-stranded DNA, Smith antigen:positiveMore

Other tests

electrony

erythematosus, photosensitive rash, erythematosus: malar rash, discoid fatigue, weight loss, alopecia, joint rash, oral ulcers, hypertension, pain, symptoms of vertigo with or without hearing loss peripheral oedema, retinal vasculitis

MRI brain

demonstra

Cogan's syndrome

History
hx of photophobia, ocular discomfort, lacrimation, fluctuating hearing loss, imbalance or vertigo

Exam
ocular redness

1st test

pure-tone audiogram:sensorineural hearing-loss patternMore

Other tests

slit-lamp ex

features of in

episcleritis, o

Wegener's granulomatosis (granulomatosis with polyangitis) see our comprehensive coverage of Wegener's granulomatosis

fluorescent absorption

History

Exam

1st test

antineutrophil cytoplasmic antibody: positive

Other

dizziness or vertigo, hearing loss, facial serous otitis media (tympanic membrane weakness; may have symptoms of nasal retracted or concave, with impaired mobility), involvement with excessive nasal crusting facial palsy, nasal lesions, or upper respiratory tract lesions

Behcet's disease see our comprehensive coverage of Behcet's syndrome

History
recurrent genital and oral ulceration, eye pain, photophobia, blurred vision, headache, hearing impairment, tinnitus, dizziness

Exam
genital ulcers, oral ulcers, red eye, acne lesions, erythema nodosum, superficial thrombophlebitis

1st test

none: diagnosis i clinical criteria

Post-surgery

History
hx of a surgical procedure (e.g., stapedectomy, middle-ear surgery, or cochlear implantation)

Exam
positive fistula test

1st test

pure-tone audiogram: elevated hearing thresholds or severe-to-profound hearingloss patternMore

Other tests

exploratory

fistula may b

windowMore

Lyme disease see our comprehensive coverage of Lyme disease

History
hx of outdoor exposure in areas with high tick populations, headache, neck pain and stiffness, sore throat, dizziness, otalgia, tinnitus, facial and motor dysfunction, hearing loss, facial weakness

Exam
erythema migrans rash (pathognomonic), neck stiffness, facial palsy

1st test

ELISA or immunoflu assay for Borrelia

species :positiveMor

Syphilis see our comprehensive coverage of Syphilis infection

History
congenital syphilis: may present with neonatal hearing loss; secondary syphilis: may present with hearing loss or vertigo with or without rash); late neurosyphilis: may present with

Exam
congenital syphilis: skin rash, dental abnormalities, craniofacial malformation; secondary syphilis: variable signs including lymphadenopathy, rash, mucosal ulceration with uveitis, meningism, seizures, nephrotic syndrome); late

1st test

treponemal-sp

serology:posit

other variable symptoms (e.g., malaise, myalgia, or without signs of more specific organ involvement (e.g., hearing loss, fluctuating hearing, or dizziness or neurosyphilis: signs of tabes dorsalis (e.g., ataxia, Argyllvertigo with or without other variable symptoms Robertson pupils, areflexia, loss of vibration/proprioception, (e.g., personality change, altered mood, loss of anal and bladder sphincter control) positive Romberg sign), may have signs memory impairment, confusion, tremor

non-treponem

serology:posit

pure-tone

audiogram:se

hearing-loss pa

HIV see our comprehensive coverage of HIV infection

History
hx of HIV infection, dizziness, and poor balance; symptoms vary according to stage of infection

Exam
polyneuropathy and ataxia; other features vary according to stage of infection but may include lymphadenopathy, weight loss, rash, and features of opportunistic infections

1st test

HIV

test:

CMV see our comprehensive coverage of Cytomegalovirus infection

History
neonate: maternal exposure to cytomegalovirus in pregnancy may present with neonatal hearing loss, dizziness, mental retardation (long term); some babies are born with severe hearing loss and other children may present with hearing loss at an older age; adult: hx of dizziness in times of stress, may be otherwise asymptomatic in immunocompetent people; immunocompromised: more severe symptoms

Exam
congenital infection, neonatal presentation: microcephaly, hepatosplenomegaly, poor muscle tone and motor function, abnormal head lag, petechiae or purpura; adult: usually normal unless immunocompromised

1st test

CMV viral

and IgGMo

audiology lossMore

HSV-1 see our comprehensive coverage of Herpes simplex virus infection

History
hx of hearing loss and dizziness; may be preceded by a herpetic skin lesion (burning sensation followed by vesicle formation); usually oral but may be genital)

Exam
may be normal or may have herpetic skin lesions (usually oral but may be genital)

1st test

pure-tone audiogr

hearing-loss patter

type-specific HSV

assay: positive ant