The Evaluation of the Dizzy Patient
Author: Brad Johnson, MD (EM Resident Physician, Henry Ford Hospital) // Editors: Justin Bright, MD and Alex Koyfman, MD
For many physicians, dizziness is one of the most dreaded chief complaints to take care of. Whether you’re experiencing it after a long Saturday night, or you’re seeing it as your first chief complaint for the day, it can be very frustrating to get to the root of the problem. I believe the frustration comes from the ambiguity of the symptoms the patient is experiencing. So, in an attempt to make things a bit easier, I’ll first try and remove the cloak of confusion associated with dizziness by breaking it down into different pathology classes. Then, I’ll focus on physical exam techniques that can aid with the diagnosis.
Typically the etiology of a patient’s dizziness can be determined with a thorough history and detailed exam, prior to any imaging studies. In 2008, Newman-Toker et al published a cross-sectional study spanning 13 years involving over 9,000 patients. The study demonstrated that 32.9% of the time dizziness can be attributed to the otologic/vestibular system. In addition, Navi et al published a study in 2012, showing that only 5% of patients presenting with dizziness were found to have a serious neurological condition. In that study, the majority of patients with dizziness were found to have vertigo (32%) or orthostatic hypotension (13%). For these reasons, I will be focusing mainly on the vestibular system and how to thoroughly assess your patient for vertigo.
The most important aspect of evaluating a patient with “dizziness” is the history. Do they feel like the sensation of spinning? This is the most common sensation experienced by patients with vertigo. What if the patient says they feel like they’re going to pass out or actually did pass out? This is more likely going to be presyncope or syncope, which is often associated with the cardiovascular system. What if the patient says they feel like they’re drunk or are having difficulty walking? This is disequilibrium and is often associated with the cerebellum. Sometimes the patient is experiencing long-lasting dizziness for months, but simply can’t articulate the way it feels. Typically with vertigo or CNS causes of dizziness, the nervous system adapts to the defect, meaning the dizziness will subside over several weeks. Therefore, dizziness lasting several months is usually unlikely to be from a CNS defect. As shown by Staab et al in 2007 by a prospective cohort spanning 6 years and evaluating over 300 patients with chronic dizziness (>3 months), 59% of the time it was attributed to an anxiety disorder. But, of course, this would be a diagnosis of exclusion on the ED.
Although symptom quality can help in defining the dizziness, it is also important not to rely too much on it. Stanton et al demonstrated that an overreliance on quality of symptoms while overlooking other factors can often lead to unnecessary testing. Other equally important factors to keep in mind are eliciting any exacerbating factors and associated symptoms. For instance, typically vertigo will be worse with head movement, regardless of whether it is central or peripheral; whereas syncope or presyncope tends to worsen with exertion or upon standing. Psychogenic causes tend to be evoked by certain social or fear invoking situations.
In regards to associated symptoms, nystagmus and hearing loss tend to be associated with vertigo. More specifically, central vertigo is usually associated with vertical nystagmus, CN deficits and ataxia. Peripheral vertigo is typically associated with hearing loss, tinnitus, horizontal nystagmus, and lasting only seconds to minutes. It’s also important to remember that cerebellar infarcts can mimic peripheral vestibulopathy, which is typically associated with severe vertigo and prominent nystagmus. At times it may be associated with a sensation of the trunk being pulled to the side of the lesion. If the “dizziness” is associated with chest pain, shortness of breath, or diaphoresis, every instinct should be screaming CARDIOPULMONARY!!!!! Finally, a postural component, melena, decreased PO intake, or vaginal bleeding is often associated with presyncope likely secondary to hypovolemia. As you can see, the most important factors within the history include quality, eliciting/exacerbating factors and associated symptoms, all of which are equally important in narrowing down the diagnosis.
Now that you’ve narrowed it down with your history, we can move on to physical exam maneuvers. The HINTS exam is one of the newer and most promising exams, which can help differentiate between peripheral and central vertigo. It is a 3 part exam standing for Head Impulse, Nystagmus, and Test of Skew. This was shown by Kattah et al in a prospective cross-sectional study with rapid onset vertigo, nystagmus, nausea/vomiting, head-motion intolerance, and unsteady gait with 1 or greater stroke risk factor(s), to have a 100% sensitivity and 96% specificity for stroke. The first part of the exam (head impulse) involves having the patient fixate on a stationary object, usually the examiners nose, while turning their head left and right. In cases of peripheral vertigo, the patient will lose fixation when turning towards the affected side, causing movement of the eyes away from the target. This will be followed by a corrective saccade back towards the fixated target. The corrective saccade back towards the target is considered a positive test. In central vertigo, there will be eye deviation without a corrective saccade, and this is considered a negative test. Below is an example of a positive head impulse exam.
The next part of the exam is simply assessing the direction of nystagmus. A unidirectional, horizontal nystagmus (fast phase beating away from affected side) is consistent with peripheral vertigo. Conversely, a rotatory, vertical or direction-changing horizontal nystagmus (fast phase of nystagmus changes dependent on direction of gaze) signifies a central vertigo. Below is an example of vertical nystagmus.
The last part of the exam, skew deviation, involves again having the patient fixate on a stationary object, while alternating the covering of each eye. A central lesion leads to vertical misalignment, meaning that the covered eye will drift either up or down and once uncovered you will see the compensation of the eye back to the fixated object. Therefore, a normal head impulse (no corrective saccade), vertical, rotatory, or direction-changing nystagmus, and skew deviation will typically indicate a central lesion. Not only does the sensitivity and specificity reach close to 100%, it was also shown by Newman-Toker et al to have a greater sensitivity than MRI within the first 48hrs. This is an exam that should be performed in all of your vertigo patients and does not take very long to perform. Below is a positive skew deviation test.
Moving on to the most well-known and commonly used exam maneuver is the Dix-Hallpike (which has an 80% sensitivity and 75% specificity for posterior semicircular canal BPPV) and the Epley maneuver. The Dix-Hallpike maneuver is performed by having your patient quickly go from sitting to lying flat and then turn their head 45 degrees. This should evoke symptoms and nystagmus. If you have a positive nystagmus finding, you can proceed directly into the Epley maneuver, which is the Dix-Hallpike followed by moving the head 180 degrees in the opposite direction. Another exam maneuver which can be used to assess for posterior semicircular canal BPPV, which has been shown to have greater sensitivity with similar specificity when compared to the Dix-Hallpike, is the side-lying maneuver. This involves turning the patient’s head 45 degrees away from the side being tested while sitting upright, then lowering them onto the shoulder of the side being tested. This is more often used in patients with limited neck mobility, where the Dix-Hallpike may be difficult to perform. But, what do you do if you have a negative Dix-Hallpike or side-lying maneuver? You should then perform the supine roll test. This involves the patient laying supine with the head in 30 degrees of flexion and then turning it to either side. This test is more specific than Dix-Hallpike for lateral canal BPPV (Dix-Hallpike usually associated with posterior canal) and is treated with the Epley as well.
A new maneuver shown to have positive diagnostic value is the Pen Light Cover Test. This uses the concept that peripheral nystagmus tends to increase with visual fixation and central nystagmus remains unaffected. This test involves evoking nystagmus via the Caloric reflex test followed by intermittently occluding one eye while shining a pen light into the opposite eye (preventing visual fixation). A positive test suggesting a peripheral cause will lead to increased nystagmus. The Romberg Test may also be helpful in differentiating peripheral vs central. In peripheral unilateral disorders, the patient tends to favor and sway to the side of pathology. Whereas with central there is no favoring of side and it tends to vary. Now that we’ve covered the complexities of establishing peripheral vs central vertigo, we can move on to the easier to assess causes of “dizziness”.
What about presyncope/syncope? As shown by Newman-Toker et al, the cardiovascular system is the cause of “dizziness” 21.1% of the time. Subsequently, the main focus during this exam is going to be the cardiovascular system. The first thing to start with is going to be the vital signs. Beginning with orthostatic assessment. Although orthostatic vital signs have a very poor sensitivity, Baraff et al showed a specificity of 98% when using a change in pulse rate >20, with a sensitivity of 17%. Therefore, there is clearly no utilization of orthostatics at ruling out hypovolemia but, it is a reliable test at ruling in hypovolemia. Cardiac auscultation can be helpful at identifying murmurs, for those with the really expensive stethoscopes or a calm, quiet ED. However, even more helpful will be an EKG. Lastly, let’s not forget the guaiac, which should be considered in all syncope/presyncope patients to assess for GI bleed. Ultimately, the most important things YOU CAN NOT MISS are the time-sensitive killers such as MI, PE, or CVA (usually associated with neurologic deficits).
Finally, we come to psychogenic causes of “dizziness”. Unfortunately, there are not many physical exam maneuvers that can help establish psychogenic causes of “dizziness”. Instead this will be a diagnosis of exclusion and will rely heavily on history. A history of depression, anxiety, panic disorder, somatization, alcohol abuse, or personality disorder may suggest psychogenic cause. Once you have appropriately ruled out cardiogenic, pulmonary, nervous system, electrolyte/metabolic, and volume causes of dizziness, you can lean more towards psychogenic.
To wrap it all up, the accurate diagnosis of “dizziness” can typically be made prior to ordering any labs or imaging. Beginning with a thorough history including quality, eliciting/exacerbating factors, and associated symptoms. This should be followed by the HINTS exam, which should be performed in all of your dizzy patients and if positive for peripheral vertigo can be followed by the Dix-Hallpike, side-lying maneuver, or supine roll test. All of these exams should be performed in conjunction with a thorough neurological exam. Once a neurological cause is ruled out, a thorough cardiovascular exam should be performed. Include an EKG, not only on patients for which you suspect a cardiovascular cause, but also for patient’s you suspect a neurological cause to rule out A-fib. Finally, if all else fails and you’re unable to find a cause for long standing “dizziness” in a patient with significant psychiatric history, then it might be time for a psych consult.
References // Further Reading:
-Stanton VA, Hsieh YH, Camargo CA Jr, et al. Overreliance on symptom quality in diagnosing dizziness: results of a multicenter survey of emergency physicians. Mayo Clin Proc 2007; 82:1319
-Bhattacharyya N, Baugh RF, Orvidas L, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 2008; 139:S47
-Navi BB, Kamel H, Shah MP, Grossman AW, Wong C, Poisson SN, et al. Rate and predictors of serious neurologic causes of dizziness in the emergency department. Mayo Clin Proc. Nov 2012;87(11):1080-8.
-Newman-Toker DE, Sharma P, Chowdhury M, et al. Penlight-cover test: a new bedside method to unmask nystagmus. J Neurol Neurosurg Psychiatry 2009; 80:900
-Newman-Toker DE, Hsieh YH, Camargo CA Jr, et al. Spectrum of dizziness visits to US emergency departments: cross-sectional analysis from a nationally representative sample. Mayo Clin Proc 2008; 83:765.
-Kattah JC, Talkad AV, Wang DZ, et al. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke 2009; 40:3504.
-Newman-Toker DE, Kerber KA, Hsieh YH, et al. HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness. Acad Emerg Med 2013; 20:986.
-Baraff LJ, Schriger DL, et al. Orthostatic vital signs: variation with age, specificity and sensitivity in detecting 450-mL blood loss. Am J Emerg Med 1992 Mar; 10(2): 99-103
-Staab JP, Ruckenstein M. Expanding the differential diagnosis of chronic dizziness. Arch Oto HNS 2007, 133, 170-176
-http://emcrit.org/podcasts/posterior-stroke/ and http://emcrit.org/misc/posterior-stroke-video/