Dizziness

Abstract

Dizziness and vertigo are among the most common symptoms to bring a patient to a neurologist. Because symptoms are often vague and imprecise, a systematic approach is essential. By categorizing vestibular disorders based on timing, triggers, and duration, as well as through focused oculomotor and vestibular examinations, the vast majority of neuro-otologic diagnoses can be made at the bedside. Here the authors discuss historical and examination pearls for the most common neuro-otologic disorders.

Keywords

vertigo - dizzy - neuro-otology - oculomotor - acute vestibular syndrome

• References

• 1 Bisdorff A, Von Brevern M, Lempert T, Newman-Toker DE. Classification of vestibular symptoms: towards an international classification of vestibular disorders. J Vestib Res 2009; 19 (1–2) 1-13
• 2 Newman-Toker DE, Edlow JA. TiTrATE: a novel, evidence-based approach to diagnosing acute dizziness and vertigo. Neurol Clin 2015; 33 (3) 577-599 , viii
• 3 Bisdorff AR, Staab JP, Newman-Toker DE. Overview of the International Classification of Vestibular Disorders. Neurol Clin 2015; 33 (3) 541-550 , vii
• 4 Brandt T, Strupp M, Dieterich M. Five keys for diagnosing most vertigo, dizziness, and imbalance syndromes: an expert opinion. J Neurol 2014; 261 (1) 229-231
• 5 Kerber KA. Acute constant dizziness. Continuum (Minneap Minn) 2012; 18 (5 Neuro-otology): 1041-1059
• 6 Ghavami Y, Mahboubi H, Yau AY, Maducdoc M, Djalilian HR. Migraine features in patients with Meniere's disease. Laryngoscope 2016; 126 (1) 163-168
• 7 Kaski D, Davies R, Luxon L, Bronstein AM, Rudge P. The Tullio phenomenon: a neurologically neglected presentation. J Neurol 2012; 259 (1) 4-21
• 8 Minor LB. Superior canal dehiscence syndrome. Am J Otol 2000; 21 (1) 9-19
• 9 Minor LB, Solomon D, Zinreich JS, Zee DS. Sound- and/or pressure-induced vertigo due to bone dehiscence of the superior semicircular canal. Arch Otolaryngol Head Neck Surg 1998; 124 (3) 249-258
• 10 Newman-Toker DE, Cannon LM, Stofferahn ME, Rothman RE, Hsieh YH, Zee DS. Imprecision in patient reports of dizziness symptom quality: a cross-sectional study conducted in an acute care setting. Mayo Clin Proc 2007; 82 (11) 1329-1340
• 11 Kerber KA, Newman-Toker DE. misdiagnosing dizzy patients: common pitfalls in clinical practice. Neurol Clin 2015; 33 (3) 565-575 , viii
• 12 Leigh RJ, Zee DS. The Neurology of Eye Movements. 5th ed. New York: Oxford University Press; 2015
• 13 Suzuki Y, Matsuda T, Washio N, Ohtsuka K. Transition from upbeat to downbeat nystagmus observed in a patient with Wernicke's encephalopathy. Jpn J Ophthalmol 2005; 49 (3) 220-222
• 14 Strupp M, Fischer C, Hanß L, Bayer O. The takeaway Frenzel goggles: a Fresnel-based device. Neurology 2014; 83 (14) 1241-1245
• 15 Zee DS. Ophthalmoscopy in examination of patients with vestibular disorders. Ann Neurol 1978; 3 (4) 373-374
• 16 Torres-Russotto D, Landau WM, Harding GW, Bohne BA, Sun K, Sinatra PM. Calibrated finger rub auditory screening test (CALFRAST). Neurology 2009; 72 (18) 1595-1600
• 17 Petersen JA, Wichmann WW, Weber KP. The pivotal sign of CANVAS. Neurology 2013; 81 (18) 1642-1643
• 18 Koo JW, Kim JS, Hong SK. Vibration-induced nystagmus after acute peripheral vestibular loss: comparative study with other vestibule-ocular reflex tests in the yaw plane. Otol Neurotol 2011; 32 (3) 466-471
• 19 Choi KD, Oh SY, Kim HJ, Koo JW, Cho BM, Kim JS. Recovery of vestibular imbalances after vestibular neuritis. Laryngoscope 2007; 117 (7) 1307-1312
• 20 Park H, Hong SC, Shin J. Clinical significance of vibration-induced nystagmus and head-shaking nystagmus through follow-up examinations in patients with vestibular neuritis. Otol Neurotol 2008; 29 (3) 375-379
• 21 Kim JS, Ahn KW, Moon SY, Choi KD, Park SH, Koo JW. Isolated perverted head-shaking nystagmus in focal cerebellar infarction. Neurology 2005; 64 (3) 575-576
• 22 Choi KD, Oh SY, Park SH, Kim JH, Koo JW, Kim JS. Head-shaking nystagmus in lateral medullary infarction: patterns and possible mechanisms. Neurology 2007; 68 (17) 1337-1344
• 23 Huh YE, Koo JW, Lee H, Kim JS. Head-shaking aids in the diagnosis of acute audiovestibular loss due to anterior inferior cerebellar artery infarction. Audiol Neurootol 2013; 18 (2) 114-124
• 24 Califano L, Mazzone S, Salafia F. Utility of the hyperventilation test in the evaluation of the dizzy patient. Curr Opin Otolaryngol Head Neck Surg 2013; 21 (5) 487-491
• 25 Zwergal A, Rettinger N, Frenzel C, Dieterich M, Brandt T, Strupp M. A bucket of static vestibular function. Neurology 2009; 72 (19) 1689-1692
• 26 D'Onofrio F. Vertical eye movements during horizontal head impulse test: a new clinical sign of superior vestibular neuritis. Acta Otorhinolaryngol Ital 2013; 33 (6) 418-424
• 27 Tjernström F, Nyström A, Magnusson M. How to uncover the covert saccade during the head impulse test. Otol Neurotol 2012; 33 (9) 1583-1585
• 28 Lee H. Audiovestibular loss in anterior inferior cerebellar artery territory infarction: a window to early detection?. J Neurol Sci 2012; 313 (1–2) 153-159
• 29 Kim SH, Park SH, Kim HJ, Kim JS. Isolated central vestibular syndrome. Ann N Y Acad Sci 2015; 1343 (1) 80-89
• 30 Chen L, Todd M, Halmagyi GM, Aw S. Head impulse gain and saccade analysis in pontine-cerebellar stroke and vestibular neuritis. Neurology 2014; 83 (17) 1513-1522
• 31 Park HK, Kim JS, Strupp M, Zee DS. Isolated floccular infarction: impaired vestibular responses to horizontal head impulse. J Neurol 2013; 260 (6) 1576-1582
• 32 Wong AM, Colpa L, Chandrakumar M. Ability of an upright-supine test to differentiate skew deviation from other vertical strabismus causes. Arch Ophthalmol 2011; 129 (12) 1570-1575
• 33 Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. 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 (11) 3504-3510
• 34 Kim JS, Zee DS. Clinical practice. Benign paroxysmal positional vertigo. N Engl J Med 2014; 370 (12) 1138-1147
• 35 Gold DR, Morris L, Kheradmand A, Schubert MC. Repositioning maneuvers for benign paroxysmal positional vertigo. Curr Treat Options Neurol 2014; 16 (8) 307
• 36 Choi JY, Kim JH, Kim HJ, Glasauer S, Kim JS. Central paroxysmal positional nystagmus: characteristics and possible mechanisms. Neurology 2015; 84 (22) 2238-2246
• 37 Polensek SH, Tusa RJ. Nystagmus during attacks of vestibular migraine: an aid in diagnosis. Audiol Neurootol 2010; 15 (4) 241-246
• 38 Furman JM, Balaban CD. Vestibular migraine. Ann N Y Acad Sci 2015; 1343: 90-96
• 39 Salviz M, Yuce T, Acar H, Karatas A, Acikalin RM. Propranolol and venlafaxine for vestibular migraine prophylaxis: a randomized controlled trial. Laryngoscope 2016; 126 (1) 169-174
• 40 Shepard NT. Differentiation of Ménière's disease and migraine-associated dizziness: a review. J Am Acad Audiol 2006; 17 (1) 69-80
• 41 Gold DR, Zee DS. Neuro-ophthalmology and neuro-otology update. J Neurol 2015; 262 (12) 2786-2792
• 42 Choi JH, Seo JD, Choi YR , et al. Inferior cerebellar peduncular lesion causes a distinct vestibular syndrome. Eur J Neurol 2015; 22 (7) 1062-1067
• 43 Arbusow V, Schulz P, Strupp M , et al. Distribution of herpes simplex virus type 1 in human geniculate and vestibular ganglia: implications for vestibular neuritis. Ann Neurol 1999; 46 (3) 416-419
• 44 Strupp M, Zingler VC, Arbusow V , et al. Methylprednisolone, valacyclovir, or the combination for vestibular neuritis. N Engl J Med 2004; 351 (4) 354-361
• 45 Goudakos JK, Markou KD, Psillas G, Vital V, Tsaligopoulos M. Corticosteroids and vestibular exercises in vestibular neuritis. Single-blind randomized clinical trial. JAMA Otolaryngol Head Neck Surg 2014; 140 (5) 434-440
• 46 Fishman JM, Burgess C, Waddell A. Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis). Cochrane Database Syst Rev 2011; (5) CD008607
• 47 Jeong SH, Kim HJ, Kim JS. Vestibular neuritis. Semin Neurol 2013; 33 (3) 185-194
• 48 Herdman SJ. Vestibular rehabilitation. Curr Opin Neurol 2013; 26 (1) 96-101
• 49 Kim YH, Kim KS, Kim KJ, Choi H, Choi JS, Hwang IK. Recurrence of vertigo in patients with vestibular neuritis. Acta Otolaryngol 2011; 131 (11) 1172-1177
• 50 Chien WW, Carey JP, Minor LB. Canal dehiscence. Curr Opin Neurol 2011; 24 (1) 25-31
• 51 Streubel SO, Cremer PD, Carey JP, Weg N, Minor LB. Vestibular-evoked myogenic potentials in the diagnosis of superior canal dehiscence syndrome. Acta Otolaryngol Suppl 2001; 545: 41-49
• 52 Zuniga MG, Janky KL, Nguyen KD, Welgampola MS, Carey JP. Ocular versus cervical VEMPs in the diagnosis of superior semicircular canal dehiscence syndrome. Otol Neurotol 2013; 34 (1) 121-126
• 53 Rosengren SM, Kingma H. New perspectives on vestibular evoked myogenic potentials. Curr Opin Neurol 2013; 26 (1) 74-80
• 54 Belden CJ, Weg N, Minor LB, Zinreich SJ. CT evaluation of bone dehiscence of the superior semicircular canal as a cause of sound- and/or pressure-induced vertigo. Radiology 2003; 226 (2) 337-343
• 55 Minor LB. Labyrinthine fistulae: pathobiology and management. Curr Opin Otolaryngol Head Neck Surg 2003; 11 (5) 340-346
• 56 Best C, Gawehn J, Krämer HH , et al. MRI and neurophysiology in vestibular paroxysmia: contradiction and correlation. J Neurol Neurosurg Psychiatry 2013; 84 (12) 1349-1356
• 57 Hüfner K, Barresi D, Glaser M , et al. Vestibular paroxysmia: diagnostic features and medical treatment. Neurology 2008; 71 (13) 1006-1014
• 58 Hain TC, Cherchi M, Yacovino DA. Bilateral vestibular loss. Semin Neurol 2013; 33 (3) 195-203
• 59 Porciuncula F, Johnson CC, Glickman LB. The effect of vestibular rehabilitation on adults with bilateral vestibular hypofunction: a systematic review. J Vestib Res 2012; 22 (5–6) 283-298
• 60 Ahmed RM, Hannigan IP, MacDougall HG, Chan RC, Halmagyi GM. Gentamicin ototoxicity: a 23-year selected case series of 103 patients. Med J Aust 2012; 196 (11) 701-704
• 61 Kattah JC, Dhanani SS, Pula JH, Mantokoudis G, Saber Tehrani AS, Newman-Toker NE. Vestibular signs of thiamine deficiency during the early phase of suspected Wernicke encephalopathy. Neurol Clin Pract 2013; 3 (6) 460-468
• 62 Zingler VC, Weintz E, Jahn K , et al. Causative factors, epidemiology, and follow-up of bilateral vestibulopathy. Ann N Y Acad Sci 2009; 1164: 505-508
• 63 Rinne T, Bronstein AM, Rudge P, Gresty MA, Luxon LM. Bilateral loss of vestibular function: clinical findings in 53 patients. J Neurol 1998; 245 (6–7) 314-321
• 64 Staab JP. Chronic subjective dizziness. Continuum (Minneap Minn) 2012; 18 (5 Neuro-otology): 1118-1141
• 65 Brandt T. Phobic postural vertigo. Neurology 1996; 46 (6) 1515-1519
• 66 Ruckenstein MJ, Staab JP. Chronic subjective dizziness. Otolaryngol Clin North Am 2009; 42 (1) 71-77, ix
• 67 Staab JP, Ruckenstein MJ. Expanding the differential diagnosis of chronic dizziness. Arch Otolaryngol Head Neck Surg 2007; 133 (2) 170-176
• 68 Meurer WJ, Low PA, Staab JP. Medical and psychiatric causes of episodic vestibular symptoms. Neurol Clin 2015; 33 (3) 643-659 , ix