Clinical Presentation
Associated Symptoms Occurring with Vertigo
Associated symptoms occurring with vertigo can provide important diagnostic clues. A feeling of fullness in the ear is commonly seen in acoustic neuroma and Meniere’s disease, while ear or mastoid pain may suggest acoustic neuroma, acute middle ear disease, or herpes zoster oticus. Facial weakness is also associated with acoustic neuroma. The presence of neurologic findings may indicate conditions such as cerebellopontine angle tumors, cerebrovascular disease, or multiple sclerosis. Headaches can occur in acoustic neuroma and migraines. Hearing loss is linked to Meniere’s disease, perilymphatic fistula, acoustic neuroma, transient ischemic attack (TIA) or stroke involving the anterior inferior cerebellar artery, herpes zoster oticus, cholesteatoma, and otosclerosis. Imbalance may be observed in acute vestibular neuronitis, cerebellopontine angle tumors, and Meniere’s disease, while tinnitus is commonly reported in acute labyrinthitis, acoustic neuroma, and Meniere’s disease. Nausea and vomiting frequently accompany vertigo in conditions such as acute vestibular neuronitis, benign paroxysmal positional vertigo, Meniere’s disease, and cerebrovascular stroke. If neurologic symptoms appear as well, central causes of vertigo should be considered.
Tiền sử bệnh
Vertigo_Initial Assesment 1Past Medical History
Review past and/or current medications and history of trauma or exposure to toxins. Medications such as aminoglycosides, some diuretics, antidepressants, antipsychotics, and alcohol can cause vertigo. The presence of diabetes and hypertension puts the patient at high risk for cerebrovascular causes of vertigo.
Family History
Patients with Meniere’s disease or migraine may have a strong family history.
Khám thực thể
Check the head and neck, central nervous system, and cardiovascular system. Distinguish central from peripheral causes of vertigo.
Head and Neck Examination
Check for facial asymmetry that may suggest either peripheral facial nerve involvement or cerebrovascular disease. Examine the tympanic membrane. The presence of vesicles suggests herpes zoster oticus. Check for cholesteatoma or chronic suppurative otitis media. Apply external pressure on the tragus and if vertigo occurs, this may suggest a perilymphatic fistula. Similarly, if vertigo occurs after asking the patient to do the Valsalva maneuver, this may also be due to a perilymphatic fistula.
Neurologic Examination
Perform a complete neurologic examination to rule out central causes of vertigo, especially those that are life-threatening (eg stroke). Examine the cranial nerves. Check for palsies, sensorineural hearing loss, or nystagmus (eg vertical nystagmus due to a central cause of vertigo). Observe for certain features of nystagmus such as type, intensity, latency, spontaneity, duration, direction, fatigue, suppression by visual fixation, and associated changes with eye movements.
Cardiovascular Examination
Check for orthostatic changes in blood pressure (BP) (eg decrease in BP of ≥20 mmHg) and in pulse rate (eg an increase of ≥10 beats per minute). This may suggest autonomic dysfunction or dehydration.
Clinical Tests
Clinical tests may be used to evaluate vestibular function and to differentiate peripheral from central vertigo. The Dix-Hallpike maneuver and supine head roll test should be used with caution in patients with cervical stenosis, severe kyphoscoliosis, limited cervical range of motion, Down syndrome, severe rheumatoid arthritis, cervical radiculopathies, Paget’s disease, ankylosing spondylitis, spinal cord injuries, and morbid obesity.
Romberg Test
The Romberg test assesses peripheral proprioception and vestibular function. The Romberg test is positive when a patient can maintain balance while standing with both feet together and both eyes open but loses balance when the eyes are closed. The examiner should be ready to assist the patient in case he or she loses balance. In unilateral peripheral disorders, a patient will lean or fall to the side of the lesion.
Dix-Hallpike Maneuver
Vertigo_Initial Assesment 2The Dix-Hallpike maneuver is the gold standard for testing posterior canal BPPV. In this procedure, the patient initially sits upright while the examiner turns the patient’s head 45° to the side being tested. The examiner quickly moves the patient, whose eyes are open, from the seated position to the supine right-ear-down position, allowing the neck to hyperextend and the head to hang off the edge of the examining table 20° to 30° past the horizontal plane. The patient’s eyes are observed for rhythmic oscillation or nystagmus, and the examiner should note the latency, duration, and direction of nystagmus. A torsional upbeat of horizontal nystagmus is a positive test for benign paroxysmal positional vertigo.
Supine Head Roll Test
The supine head roll test is used in the diagnosis of lateral canal BPPV after a negative Dix-Hallpike maneuver. Initially, the patient is in a supine neutral position, after which the examiner briskly turns the patient’s head 90° to one side and observes for nystagmus. The head is then turned back to the neutral position. The same procedure is done, this time turning the head to the opposite side.
Head Impulse Test (HIT)
The head impulse test is a sensitive and specific test to detect unilateral hypofunction of the peripheral vestibular system. This may differentiate between cerebellar infarction and acute vestibular neuronitis; the head impulse test is abnormal in the latter. The examiner holds the head of the patient firmly and turns it rapidly with care to one side past the midline, then to the other side. The patient should be able to fix his or her gaze at a point behind the examiner. When the patient’s head is turned to the side of the lesion, the eyes will move with the head such that the gaze is no longer on target; this signifies an abnormal head impulse test. This may not be an appropriate test for patients with neck pathology.
Test of Skew (Cover Test)
Vertigo_Initial Assesment 3Have the patient look at your nose with their eyes. Look for vertical ocular misalignment. Cover one eye and quickly look to see if the uncovered eye moves to realign. Test for both eyes.