Download Doctor, I`m Dizzy - Continuing Medical Education

•4/21/2009
“Doctor, I’m Dizzy”
An Evidence-Based Approach to
Diagnosing Dizziness
Ronald H. Labuguen, M.D.
Associate Clinical Professor
Department of Family and Community Medicine
University of California, San Francisco
UCSF Annual Review of Family Medicine
April 20, 2009
“Dizziness” is . . .
"a disturbed sense of relationship to
space;
a sensation of unsteadiness with a
feeling of movement within the
head."
-Dorland’s Medical Dictionary
Objectives
• Be familiar with distinguishing clinical
characteristics of common causes of dizziness
• Review elements of the history and physical
examination that point to common causes of
dizziness and vertigo
• Choose imaging studies helpful in the initial
evaluation of dizziness and vertigo
After this lecture participants will be able to
• Use an evidence-based approach to the workup
of patients with dizziness
Dizziness: Common and
Debilitating
• Common: 23% of all adults
• More common in older adults: 34% of
adults 60+ yo
• Commonly debilitating:
– Persistent dizziness in 4% of all patients
– Severe incapacitation in at least 3% of all
patients
Nazareth I, Yardley L, Owen N, et al. Outcome of symptoms of dizziness in a general practice community
sample. Fam Pract 1999; 16(6): 616-8. Kroenke K, Price RK. Symptoms in the community.
Prevalence, classification, and psychiatric comorbidity. Arch Intern Med 1993; 153: 2474-80. Sloane
P, Blazer D, George LK. Dizziness in a community elderly popluation. J Am Geratr Soc 1989; 37: 101-8
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Most Common Causes
Causes of Dizziness
• Peripheral vestibular disorders (35-55%)
• Benign positional paroxysmal vertigo (BPPV)
• Acute vestibular neuronitis (AVN)
• Labyrinthitis
• Ménière’s disease
Hoffman R, Einstadter D, Kroenke K. Evaluating dizziness. Am J Med 1999;107:468-478.
Most Common Causes
• Psychiatric illness: anxiety (especially panic),
depression
• Only cause in 9% of patients
• At least contributory in up to 25%
• Dizziness can be somatic complaint in
depressed Asian patients
Sloane PD, Coeytaux RR, Beck RS, Dallara J. Dizziness: state of the science. Ann Intern Med 2001;134:823832. Ardic FN, Atesci FC. Is psychogenic dizziness the exact diagnosis?. Eur Arch Otorhinolaryngol
2006; 263: 578-81. Lawson J, Fitzgerald J, Birchall J, et al. Diagnosis of geriatric patients with severe
dizziness. J Am Geriatr Soc 1999; 47: 12-7. Hoffman R, Einstadter D, Korenke K. Evaluating dizziness.
Am J Med 1999;107:468-478. Arnault DS, Kim O. Is there an Asian idiom of distress? Somatic
Symptoms in Female Japanese and Korean Students. Arch Psychiatr Nurs. 2008 February ; 22(1): 27–
38.
Other Common Causes
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Central vestibular disorders (5%)
Presyncope (2-16%)
Dysequilibrium (1-15%)
Prescription drug toxicity (2-10%)
Hoffman R, Einstadter D, Kroenke K. Evaluating dizziness. Am J Med 1999;107:468-478.
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Less Common Causes
• Substance abuse
• Metabolic
abnormalities
• Hepatic
encephalopathy
• Electrolyte
disturbances
• Systemic and upper
respiratory infections
• Hypertension
• Trauma
• Anemia
• Alzheimer’s disease
• Parkinson’s disease
• Seizures
• Endocrine disorders
Hoffman R, Einstadter D, Kroenke K. Evaluating dizziness. Am J Med 1999;107:468-478.
Many Patients have Multiple
and/or Unknown Causes of
Dizziness
Causes of Dizziness in Children
Most common:
• Otitis media
• Chronic middle ear
effusion
• Eustachian tube
dysfunction
Less common:
• Benign paroxysmal
positional vertigo of
childhood
• Migraine
• Trauma
• Vestibular neuronitis
• Ménière’s disease
Golz A, Angel-Yeger B, Parush S. Evaluation of
balance disturbances in children with middle
Bower CM, Cotton RT. The spectrum of
ear effusion. Int J Ped Otorhinolaryngol 1998;
vertigo in children. Arch Otolaryngol
43(1): 21-6
Head Neck Surg 1995; 121: 911-5
Vertigo
Overview of Common Causes
• Multiple diagnoses are common, especially in
older patients
• 10-25% remain undiagnosed
Hoffman R, Einstadter D, Korenke K. Evaluating dizziness. Am J Med 1999;107:468-478.
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Vertigo is . . .
• . . . “a false sense of motion”
• Usually rotatory, may be linear
• Half of all dizziness complaints
• Extensive differential diagnosis
• Most cases in primary care fall under
relatively few diagnoses
Kroenke K, Lucas CA, Rosenberg ML, Scherokman B, Herbers JE, Wehrle PA et al.
Causes of persistent dizziness: a prospective study of 100 patients in ambulatory
care. Ann Int Med 1992;117:898-904.
Benign Paroxysmal Positional Vertigo
(BPPV)
• a.k.a. Benign Positional Vertigo (BPV)
• Most common cause of vertigo in
primary care
• Cause: stimulation of vestibular sense
organs by otolith
– Posterior semicircular canal
– Lateral semicircular canal
Most Common Causes of Vertigo
93% of peripheral
vertigo:
• Benign paroxysmal
positional vertigo
(BPPV)
• Acute vestibular
neuronitis (AVN)
• Ménière’s disease
• Other causes
– Drug-induced
– Psychological
– Cerebrovascular
disease
– Migraine
Hanley K, O’Dowd T. Symptoms of vertigo in general practice: a prospective study of
diagnosis. Br J Gen Pract 2002;52:809-812.
Clinical Characteristics of BPPV
• Main complaint = rotatory illusion
• Timing/duration:
– Brief episodes (seconds to few minutes)
– Variable lengths of time between episodes
– Recurrent episodes may occur over days to
weeks
• Severity:
– May affect social/occupational functioning
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Clinical Characteristics of BPPV
(cont’d)
• Aggravating factors:
– Changes in head position provoked
symptoms
• Associated symptoms:
– May have nausea, usually not vomiting
– No hearing loss
• Epidemiology:
– Typically middle aged and older patients
– Twice as many females as males
Clinical Characteristics of AVN
• Main complaint = severe constant vertigo
• Timing/duration:
– Relatively sudden onset
– Symptoms may resolve slowly over a few
days
– Sometimes shorter recurrent attacks over
days or weeks
Acute Vestibular Neuronitis (AVN)
• a.k.a. vestibular neuritis, epidemic
vertigo
• Nomenclature can be confusing; often
confused with acute/viral labyrinthitis
• Cause: inflammation/stimulation of
vestibular nerve caused by viral
infection
Clinical Characteristics of AVN
(cont’d)
• Aggravating factors:
– Head movement can worsen symptoms
• Associated symptoms
– Nausea; half of patients with vomiting
• Epidemiology
– Affects patients at any age
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Ménière’s Disease
• a.k.a. Ménière’s syndrome
• Cause: Not well understood
– “Endolymphatic hydrops” pathological
finding
Saeed SR. Diagnosis and treatment of Ménière’s disease. BMJ 1998:316:368-372.
Clinical Characteristics of
Ménière’s Disease (cont’d)
• Severity: Waxing then waning course
• Associated symptoms:
– Nausea, vomiting
– Pallor
– Sweating
• Epidemiology:
– Onset in early to mid adulthood
Clinical Characteristics of
Ménière’s Disease
• Main complaints = Vertigo associated
with
– Hearing loss
• Fluctuating course of low, then high frequency
sensorineural hearing loss
• Eventually progresses to permanent hearing
loss
– Tinnitus
– Aural fullness
• Timing/duration:
– Episodes last several minutes to hours
– Waxing/waning course long-term
Drugs That Can Cause Vertigo
• Alcohol
• Aminoglycosides
• Anticonvulsants
– Phenytoin
• Antidepressants
• Antihypertensives
• Barbiturates
• Cocaine
• Diuretics
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– Furosemide
Nitroglycerin
Quinine
Salicylates
Sedative/hypnotics
Froehling DA, Silverstein MD, Mohr DN, Beatty CW. Does this dizzy patient have a
serious form of vertigo? JAMA 1994;271:385-388.
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Psychological Causes of Vertigo
• Anxiety Disorders
– Panic disorder
– Agoraphobia
Yardley L, Owen N, Nazareth I, et al. Panic disorder with agoraphobia associated with
dizziness: characteristic symptoms and psychosocial sequelae. J Nerv Ment Dis 2001;
189(5): 321-7.
Clinical Characteristics of Some
Strokes That Can Cause Dizziness
• Basilar artery stroke
– may initially present as isolated dizziness
• Posterior cerebral circulation
– repeated TIA’s usually cause other
neurological symptoms as well
• Anterior inferior cerebellar artery
occlusion
– can cause dizziness and sudden unilateral
hearing loss
Cerebrovascular Disease
• Transient Ischemic Attack, Stroke
• Suspect in patients with risk factors
– Tobacco use
– Hypertension
– Diabetes mellitus
– Hypercholesterolemia
– Advanced age
Migraine
• Headaches usually accompanied by
other characteristic symptoms
• 30% of patients with migraine suffer
vertigo
• 12% with classical migraine report
vertigo as part of their aura
• Vertigo lasts minutes to hours
• Basilar migraines mimic vertebrobasilar
insufficiency
Cass SP, Furman JM, Ankerstjerne JKP, Balaban C, Yetiser S, Aydogan B. Migrainerelated vestibulopathy. Ann Otol Rhinol Laryngol 1997;106:182-189.
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Important Points
Diagnosing Dizziness
• Be familiar with common presenting
scenarios
• History alone diagnoses 75% of patients
– Distinguish between vertigo and other forms of
dizziness
– Know key questions to ask to distinguish
between different causes of dizziness
• Know key physical examination techniques
and findings
• Recognize serious causes of dizziness
History
History of the Present Illness
• Distinguish between vertigo and other
forms of dizziness
– Spinning sensation suggests vertigo
Evans JG. Transient neurological dysfunction and risk of stroke in an elderly English
population: the different significance of vertigo and non-rotatory dizziness. Age Ageing
1990;19:43-49.
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History: 3 Key Questions
• Timing/duration
• Aggravating factors
• Presence of associated symptoms
– Hearing loss
– Pain
– Nausea and vomiting
– Neurological symptoms
– Psychological symptoms
History: Timing/Duration/Onset
• How long do episodes last?
– If vertigo, the longer symptoms last, the
more likely a central cause
– Several seconds to few minutes
• BPPV
– Hours
• Ménière’s disease
• Migraine
– Weeks
History: Timing/Duration/Onset
• When does dizziness occur?
– Vertigo upon awakening associated with
peripheral vestibular disorders
• Sudden or gradual onset?
– Inner ear cause associated with more sudden
onset of vertigo
• Does severity vary over time?
– AVN: initially severe, then lessen over few days
– Ménière’s disease: attacks progressively become
more severe, then lessen in late stages of disease
History: Aggravating Factors
• Positional change – think BPPV
– Turning over in bed
– Bending over at the waist and then
straightening up
– Hyperextending the neck
• Recent URI – think AVN
• Psychosocial stress
• Psychogenic
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History: Associated Symptoms
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Hearing loss
Nausea and vomiting
Neurological symptoms
Psychological symptoms
Pain
History: Associated Symptoms
Hearing Loss: Other Serious Causes
History: Associated Symptoms
Hearing Loss – Common Causes
• Ménière’s disease
– Progressive, cumulative hearing loss with
each episode
– Associated with tinnitus, aural fullness
• Acute labyrinthitis
History: Associated Symptoms
Hearing Loss: Other Causes
• Acoustic neuroma
• Herpes zoster oticus
• Anterior Inferior Cerebellar Artery TIA
or Stroke
• Cholesteatoma
– Progressive, unilateral hearing loss
– Associated with aural fullness
– Sudden onset of hearing loss, unilateral
– Associated with other neurological
symptoms
– Associated with pain, unilateral facial nerve
palsy
– Associated with ear drainage
• Otosclerosis
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History: Associated Symptoms
• AVN
• BPPV
Nausea and Vomiting
History: Associated Symptoms
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Psychological Symptoms
Vertigo
Fainting
Agoraphobic behavior
Occupational disability
Yardley L, Owen N, Nazareth I, et al. Panic disorder with agoraphobia associated with
dizziness: characteristic symptoms and psychosocial sequelae. J Nerv Ment Dis 2001;
189(5): 321-7.
History: Associated Symptoms
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Neurological Symptoms
Weakness
Dysarthria
Vision changes
Paresthesia
Altered level of consciousness
Ataxia
Other changes in sensory and motor
function
History: Associated Symptoms
Pain
• Acute middle ear disease
• Invasive disease of the temporal bone
• Meningeal irritation
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Past Medical History
Past Medical History
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Risk factors for cerebrovascular disease
Medications
Trauma
Exposure to toxins
Psychiatric history
Psychosocial stressors
Physical Examination:
Three Key Systems
Physical Examination
• Head and neck
• Cardiovascular
• Neurological
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Physical Examination:
Head and Neck
• Pneumatic otoscopy
– Vesicles (Ramsay-Hunt syndrome)
– Cholesteatoma
– Otosclerosis
Physical Examination:
Cardiovascular
• Orthostatics (blood pressure/pulse)
– Most useful to diagnose
• Moderate or severe dehydration
• Autonomic dysfunction
– However:
• Wide range of normal
• About 50% of elderly patients have positive
orthostatic measurements
– may not be reproducible
McGee S, Abernethy WB, Simel DL. Is This Patient Hypovolemic? JAMA 1999;281(11):1022-1029.
Physical Examination:
Cardiovascular (cont’d)
• Schellong Test (100% specific)
– (+) test = systolic BP falls at least 20 mmHg
while patient stands 10-20 min
– Causes of positive test:
• Postural orthostatic tachycardia syndrome
(61% sensitive)
• Neurocardiogenic syncope (31% sensitive)
Winker R, Prager W, Haider A, et al. Schellong test in orthostatic dysregulation: a comparison
with tilt-table testing. Wien Klin Wochenschr 2005; 117(1-2): 36-41.
Physical Examination:
Cardiovascular (cont’d)
• Carotid sinus stimulation
– May document arrhythmia
– Low yield: reveals arrhythmia in 6% in
patients >60 yo w/ unexplained dizziness
– Theoretically potentially dangerous, but
danger not borne out in studies
Evans JG. Transient neurological dysfunction and risk of stroke in an elderly English population:
the different significance of vertigo and non-rotatory dizziness. Age Ageing 1990;19:43-49.
Kumar NP, Thomas A, Mudd P, et al. The usefulness of carotid sinus massage in different
patient groups. Age Ageing 2003; 32(6): 666-9.
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Physical Examination: Neurological
• Cranial nerves
– Sensorineural hearing loss (Weber, Rinné)
– Nystagmus:
• Often suppressed by visual fixation if caused by a
peripheral vestibular disorder
– Try funduscopic examination in the dark
• Spontaneous horizontal +/- rotatory is consistent
with AVN
• Vertical = 80% sensitive for vestibular nuclear or
cerebellar vermis lesions
Fife TD, Tusa RJ, Furman JM, et al. Assessment: vestibular testing techniques in adults and
children: report of the Therapeutics and Technology Assessment Subcommittee of the
American Academy of Neurology. Neurology 2000; 55(10): 1431-41.
Physical Examination: Neurological
Dix-Hallpike Maneuver
• Diagnoses posterior semicircular canal BPPV
• Patient sits upright, then head turned 30-45°
• Patient focuses on examiner as s/he lies
supine quickly (within 2 seconds)
• Onset of nystagmus or vertigo within 2-20
seconds, lasting up to 30 seconds = (+) test
• Nystagmus reverses direction when pt sits
upright again
• Intensity of induced symptoms wanes with
repeated maneuvers
Physical Examination: Neurological
(cont’d)
• Romberg’s sign
– Consistent with vestibular and/or
proprioceptive problem
– Not particularly useful in distinguishing
between causes of dizziness
Herr RD, Zun L, Mathews JJ. A directed approach to the dizzy patient. Ann Emerg Med
1989:18:664-672.
Physical Examination: Neurological
Dix-Hallpike Maneuver (cont’d)
• Videos
– Claymation video
– Computer animation
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Physical Examination: Neurological
Dix-Hallpike Maneuver (cont’d)
Supine Roll Test
• Dix-Hallpike maneuver (cont’d):
– PPV 83%, NPV 52% for BPPV
– May not be as sensitive in older patients
• Variations on Dix-Hallpike maneuver
– Supine roll test – lateral semicircular canal
BPPV
– Side-lying test
Hanley K, O’Dowd T. Symptoms of vertigo in general practice: a prospective study of diagnosis.
Br J Gen Pract 2002;52:809-812. Hoffman RM, Einstadter D, Kroenke K. Evaluating
dizziness. Am J Med 1999;107:468-78. Bhattacharyya N, Baugh RF, Orvidas L et al. Clinical
practice guideline: Benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg
2008;139:S47-S81.
Treatment of BPPV
• Particle Repositioning Maneuver
(PRM)/Canalith Repositioning (CRP)
Fife TD, Iverson DJ, Lempert T et al. Practice parameter: therapies for benign paroxysmal positional
vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the
American Academy of Neurology. Neurology 2008;70:2067-74
Treatments for BPPV:
Epley Maneuver
– Epley maneuver (better evidence)
– Semont maneuver
– Superior to Brandt-Daroff exercises
• Antihistamines/benzodiazepines not
recommended
Fife TD, Iverson DJ, Lempert T et al. Practice parameter: therapies for benign
paroxysmal positional vertigo (an evidence-based review): report of the Quality
Standards Subcommittee of the American Academy of Neurology. Neurology
2008;70:2067-74. Bhattacharyya N, Baugh RF, Orvidas L et al. Clinical practice
guideline: Benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg
2008;139:S47-S81.
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Treatments for BPPV:
Semont Maneuver
Physical Examination: Neurological
Other Qualitative Tests
• Head thrust test
– Patient fixates on target, then rapidly
rotates head to one side 45 deg
– Saccadic eye movements after head
turning may rule in unilateral
semicircular canal dysfunction
• PPV 100%, NPV 68% in one study
Oliva M, Martin Garcia MA, Bartual J, Ariza A, Garcia Teno M. The head-thrust test (HTT):
physiopathological considerations and its clinical use in daily practice. Acta Otorrinolaringol
Esp 1998;49:275-279.
Physical Examination: Neurological
Other Qualitative Tests (cont’d)
• Hyperventilation x 30 sec
– May distinguish physical vs.
psychogenic cause
• Can rule out hyperventilation
syndrome (PPV 19%, NPV 99%)
History and Physical:
Other Evidence Based Pearls
Herr RD, Zun L, Mathews JJ. A directed approach to the dizzy patient. Ann Emerg
Med 1989:18:664-672.
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Serious Causes of Dizziness
• Older age (>70), neurological deficit or
lack of vertigo predicts a serious cause of
dizziness (86% sensitivity)
• “Serious causes of dizziness” =
– Adverse effect of medication
– Central nervous system disease such as seizure
or cerebrovascular disease (stroke, transient
ischemic attack, vertebrobasilar insufficiency)
– Cardiovascular disease (arrhythmia,
hypertension, pericarditis)
Herr RD, Zun L, Mathews JJ. A directed approach to the dizzy patient. Ann Emerg Med
1989:18:664-672.
Tests Not as Useful
in Older Patients
• Weber and Rinné tests
• Dix-Hallpike maneuver
• Orthostatics
Peripheral Vestibular Disorders
• Vertigo, vomiting or both and
(+) Dix-Hallpike maneuver
suggests peripheral vestibular disorder
– Specificity 94%
– PPV 85%, LR(+)=7.6
– NPV 68%, LR(-)=0.6
Herr RD, Zun L, Mathews JJ. A directed approach to the dizzy patient. Ann Emerg Med
1989:18:664-672.
Causes of Peripheral Vertigo
• In patients with peripheral vertigo, this
matrix is accurate 60% of the time:
Hearing Loss
Episodic
Vertigo
Lawson J, Fitzgerald J, Birchall J, et al. Diagnosis of geriatric patients with severe dizziness.
J Am Geriatr Soc 1999; 47: 12-7
Persistent
Vertigo
Ménière’s
disease
Labyrinthitis
No Hearing
Loss
BPPV
AVN
Kentala E, Rauch SD. A practical assessment algorithm for diagnosis of dizziness. Otolaryngol
Head Neck Surg 2003;128:54-59.
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Qualitative vs. Quantitative
Vestibular Tests
• No evidence on sensitivity/specificity of
qualitative vestibular tests vs.
quantitative vestibular testing techniques
Dizziness Associated With Panic
• Patients with panic attacks
– Those with dizziness report higher
rates of
• Vertigo
• Fainting
• Agoraphobic behavior
• Occupational disability
Yardley L, Owen N, Nazareth I, et al. Panic disorder with agoraphobia associated with dizziness:
characteristic symptoms and psychosocial sequelae. J Nerv Ment Dis 2001; 189(5): 321-7.
No routine testing is indicated in
all patients with dizziness
Diagnostic Testing:
Evidence Based Pearls
• Study of dizzy patients in ED concluded:
– Check glucose levels in diabetic patients (to
diagnose reactive hypoglycemia)
– Monitor cardiac rhythm in patients > 45 yo
• Certain low yield tests may be performed
when indicated
– Qualitative vestibular tests
– Carotid massage
Herr RD, Zun L, Mathews JJ. A directed approach to the dizzy patient. Ann Emerg Med
1989:18:664-672.
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When to Order Neuroimaging
• Consider neuroimaging studies if:
– CNS or invasive otologic disease suggested by
exam
– acute vertigo and high risk for cerebrovascular
disease based on age and risk factors
– progressive hearing loss w/ abnormal speech
reception thresholds
Turski PA, Seidenwurm DJ, Davis PC, et al, Expert Panel on Neurologic Imaging. Vertigo and hearing
loss.
http://www.guideline.gov/summary/summary.aspx?doc_id=9602&nbr=005123&string=dizziness.
[online publication]. Reston (VA): American College of Radiology (ACR) 2006; : 8 p.
Audiometry
• May distinguish Ménière’s disease from
migraine-associated vertigo
Saeed SR. Diagnosis and treatment of Ménière’s disease. BMJ 1998:316:368-372.
Battista RA. Audiometric findings of patients with migraine-associated dizziness.
Otol Neurotol 2004; 25(6): 987-92.
MRI Preferred over CT
• MRI preferred over CT in
– patients with sensorineural hearing loss and
acute or intermittent vertigo
– patients with vertigo but without hearing
loss or neurological findings
• MRI/MRA may be useful in patients with
new-onset episodic vertigo lasting hours
to days
Turski PA, Seidenwurm DJ, Davis PC, et al, Expert Panel on Neurologic Imaging. Vertigo and hearing
loss.
http://www.guideline.gov/summary/summary.aspx?doc_id=9602&nbr=005123&string=dizziness.
[online publication]. Reston (VA): American College of Radiology (ACR) 2006; : 8 p.
Arrhythmia Monitoring
• Patient-triggered event recorders with
continuous automatic arrhythmia
detection are superior to 24 hour Holter
monitoring or patient-triggered event
recorders alone
– 24 hr Holter monitoring will miss over 1/2 of
relevant arrhythmias
– Patient-triggered event recorders capture
only about 1/6 of clinically relevant
arrhythmias
Balmelli N, Naegeli B, Bertel O. Diagnostic yield of automatic and patient-triggered ambulatory cardiac
event recording in the evaluation of patients with palpitations, dizziness, or syncope. Clin Cardiol
2003; 26(4): 173-6.
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When to Refer
• If a vestibular disorder is suspected but
not confirmed by the clinical
examination, consider neurology,
neurotology, or otolaryngology referral
An Evidence-Based Algorithm
for the Diagnosis of
Dizziness and Vertigo
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Take-Home Points
• Recognize serious causes of dizziness
– Patients >70 years old,
– Presence of neurological deficit, or
– Non-vertigo dizziness
• Serious causes of dizziness
– Medication-related
– Neurologic
– Cardiac
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Take-Home Points
• Perform the Dix-Hallpike maneuver to
diagnose patients with a peripheral
vestibular disorder (posterior
semicircular canal BPPV).
Take-Home Points
• In patients with vertigo, determine whether symptoms are
episodic or persistent, and whether hearing loss is present, in
order to distinguish between benign paroxysmal positional
vertigo, vestibular neuronitis, labyrinthitis, or Ménière’s disease.
Hearing Loss
Episodic
Vertigo
Persistent
Vertigo
Ménière’s
disease
Labyrinthitis
No Hearing
Loss
BPPV
Take-Home Points
• In patients with vertigo, determine
whether symptoms are episodic or
persistent, and whether hearing loss is
present, in order to distinguish between
benign paroxysmal positional vertigo,
vestibular neuronitis, labyrinthitis, or
Ménière’s disease.
Take-Home Points
• No routine tests are indicated in the
diagnosis of dizziness, although
– Glucose levels should be checked in diabetic
patients
– Cardiac rhythm should be monitored in
patients >45 years old
AVN
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Take-Home Points
• Magnetic resonance imaging is preferred
for neuroimaging when indicated in
patients with dizziness.
References
• Labuguen RH. Initial Evaluation of
Vertigo. Am Fam Physician
2006;73:244-51, 254.
• Labuguen RH. Dizziness. Essential
Evidence Plus (online), in press.
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