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The Dizzy Patient
4x4 Method
Dr Ahmad Alamadi FRCS
Consultant, HOD
Al Baraha Hospital
Vestibular Physiology
 Orientation of our body in space is the
primary function of the vestibular system. This
is achieved by integration of signals from
vestibular, visual and proprioceptive receptors
at the level of brain stem.
 Information regarding the movement of the
head relative to the body is largely provided
by paired vestibular sensory endorgans
Vestibular Sensory Endorgans
Cristae & Otolithic organ
Information Relay
Peripheral Vestibular
System
EYES
Proprioceptive Receptors
Central Vestibular Nuclei
Vestibulocerebellar tracts
(VCT)
Vestibulo-Ocular reflex
(VOR)
Vestibulospinal
(VST)
VOR
 Keeps a stable retinal image during head
movement
 As the head moves in one direction there
should be an equal and opposite conjugate
movement of the eyes (sometime known as
the doll’s eye maneuver)
VOR Defect
 Bilateral Defect : (for example from systemic
aminoglycoside toxicity) the patient will complain of
imbalance and a blurring of vision with head
movement better known as oscillopsia
 Unilateral defect : the equilibrium of the push-pull
forces between the inner ears is altered. This result in
a drift of the eyes away from side of lesion followed
by a quick central nervous system (CNS) mediated
saccade in a repetitive to and fro fashion better
known as nystagmus.
Nystagmus is the cardinal sign of a central or
peripheral vestibular disorder
History Steps
1. Organic Vs Psychogenic
2. Vestibular Vs Non vestibular
3. Peripheral Vs Central
4. Which Peripheral Vestibular Disorder
Organic Vs Psychogenic
Features
Organic vestibular
Psychogenic
Duration
Usually well defined i.e. seconds,
minutes or hours
(never a “flash”)
Variable from a “flash” to days
Not well defined
Frequency
Except for benign paroxysmal
positional vertigo (BPPV), rarely
more than once a day
Constant or many times a day
Head Movement
Intensifies symptoms
Symptoms usually unaffected
Ataxia during spell
Usually prominent
Insignificant
Effect of Hyperventilation
Not like the attack
Often reproduces symptoms accurately
Vestibular Vs Non vestibular
 True Vertigo (hallucination of movement
relative to self) Vs Non specific Dizziness
 Note patient with non specific dizziness need
to be investigated for cardiac and
neurological causes.
 Patients with true vertigo have a vestibular
disease which can be central or peripheral
Peripheral Vs Central
 Ask for associated symptoms i.e. discharge,
tinnitus, aural fullness and hearing loss
 Ask for focal neurological complaints i.e.
diplopia, dysphagia, dysarthria, paresis,
parasthesia or incontinence and LOC.
Inner ear disorders should never be associated
with a loss of consciousness
Which Peripheral Vestibular Disorder

Benign paroxysmal positional vertigo (BPPV)
seconds; several attacks /day; positional

Meniere's disease
minutes to hours; tinnitus; fluctuating hearing loss; aural fullness

Recurrent Vestibulopathy
minutes to hours

Vestibular Neuronitis (acute viral labyrinthitis)
Hours to days
Examination Steps
1. Otological examination
2. Neurological examination
3. Special clinical vestibular tests
4. Important Diagnostic Tests
Otological examination
 Otoscopy
 Hearing assessment (Weber and Rinne tests)
 Fistula Test
Neurological examination
 Cranial Nerves
 Cerebellar Tests
 Oculomotor Tests
Smooth pursuit, saccades, visual fixation and vergence
 Balance Tests
proprioception, Romberg’s and tandem gait tests (both eyes
open and closed).
When Smooth Pursuit is Normal it would be
unlikely for a central disorder to be present
Special clinical vestibular tests
 The Halmagyi maneuver
 The head shake test
 The oscillopsia test
 VOR suppression test
Important Diagnostic Tests
 Dix-Hallpike Positional Test
 Hyperventilation Test
Conclusion
 4 steps in History
x
=
 4 steps in Examination
99% Diagnosis
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