The Outpatient Approach to Dizziness

Abstract

The evaluation of the dizzy patient is complicated by many common pitfalls. The patient's description of symptoms and the standard neurologic examination are often nonspecific or unrevealing, and neuroimaging is most often normal. Over the past several years, research has demonstrated that a refocusing of history taking results in more reliable and diagnostically helpful information. This can guide a targeted expansion of the exam, often with an emphasis on eye movements.

Keywords

vertigo - vestibular - dizziness

Publikationsverlauf

Artikel online veröffentlicht:
26. November 2021

• References

• 1 Newman-Toker DE, Cannon LM, Stofferahn ME, Rothman RE, Hsieh Y-H, Zee DS. Imprecision in patient reports of dizziness symptom quality: a cross-sectional study conducted in an acute care setting. In: Mayo Clinic Proceedings [Internet]. Elsevier; 2007. :1329–1340 [cited February 9, 2016]. Accessed December 29, 2020 at: http://www.sciencedirect.com/science/article/pii/S0025619611614110
• 2 Newman-Toker DE, Edlow JA. TiTrATE: a novel, evidence-based approach to diagnosing acute dizziness and vertigo. Neurol Clin 2015; 33 (03) 577-599 , viii
• 3 Versino M, Hurko O, Zee DS. Disorders of binocular control of eye movements in patients with cerebellar dysfunction. Brain 1996; 119 (Pt 6): 1933-1950
• 4 Newman-Toker DE, Sharma P, Chowdhury M, Clemons TM, Zee DS, Della Santina CC. Penlight-cover test: a new bedside method to unmask nystagmus. J Neurol Neurosurg Psychiatry 2009; 80 (08) 900-903
• 5 Zee DS. Ophthalmoscopy in examination of patients with vestibular disorders. Ann Neurol 1978; 3 (04) 373-374
• 6 Robinson DA, Zee DS, Hain TC, Holmes A, Rosenberg LF. Alexander's law: its behavior and origin in the human vestibulo-ocular reflex. Ann Neurol 1984; 16 (06) 714-722
• 7 Dumas G, Curthoys IS, Lion A, Perrin P, Schmerber S. The skull vibration-induced nystagmus test of vestibular function-a review. Front Neurol 2017; 8: 41
• 8 Vargas Gamarra MF, Krstulovic C, Pérez Guillén V, Pérez-Garrigues H. Ipsilesional nystagmus induced by vibration in subjects with Ménière's disease or vestibular schwannoma. Otol Neurotol 2017; 38 (06) e168-e172
• 9 Zamora EG, Araújo PE-S, Guillén VP. et al. Parameters of skull vibration-induced nystagmus in normal subjects. Eur Arch Otorhinolaryngol 2018; 275 (08) 1955-1961
• 10 Yang T-H, Lee JH, Oh S-Y, Kang J-J, Kim J-S, Dieterich M. Clinical implications of head-shaking nystagmus in central and peripheral vestibular disorders: is perverted head-shaking nystagmus specific for central vestibular pathology?. Eur J Neurol 2020; 27 (07) 1296-1303
• 11 Califano L, Iorio G, Salafia F, Mazzone S, Califano M. Hyperventilation-induced nystagmus in patients with vestibular schwannoma. Otol Neurotol 2015; 36 (02) 303-306
• 12 Ward BK, Gold DR. Tinnitus, oscillopsia, and hyperventilation-induced nystagmus: vestibular paroxysmia. Open J Clin Med Case Rep 2016; 2 (07) 1100
• 13 Walker MF, Zee DS. The effect of hyperventilation on downbeat nystagmus in cerebellar disorders. Neurology 1999; 53 (07) 1576-1579
• 14 Califano L, Melillo MG, Vassallo A, Mazzone S. Hyperventilation-induced nystagmus in a large series of vestibular patients. Acta Otorhinolaryngol Ital 2011; 31 (01) 17-26
• 15 Demer JL, Honrubia V, Baloh RW. Dynamic visual acuity: a test for oscillopsia and vestibulo-ocular reflex function. Am J Otol 1994; 15 (03) 340-347
• 16 Kattah JC, Talkad AV, Wang DZ, Hsieh Y-H, 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
• 17 Newman-Toker DE, Kerber KA, Hsieh Y-H. et al. HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness. Acad Emerg Med 2013; 20 (10) 986-996
• 18 Fakhran S, Alhilali L, Branstetter IV BF. Yield of CT angiography and contrast-enhanced MR imaging in patients with dizziness. AJNR Am J Neuroradiol 2013; 34 (05) 1077-1081
• 19 Shepard NT, Jacobson GP. The caloric irrigation test. Handb Clin Neurol 2016; 137: 119-131
• 20 Weber KP, MacDougall HG, Halmagyi GM, Curthoys IS. Impulsive testing of semicircular-canal function using video-oculography. Ann N Y Acad Sci 2009; 1164: 486-491
• 21 Halmagyi GM, Chen L, MacDougall HG, Weber KP, McGarvie LA, Curthoys IS. The Video Head Impulse Test. Front Neurol 2017; 8: 258
• 22 Judge PD, Janky KL, Barin K. Can the video head impulse test define severity of bilateral vestibular hypofunction?. Otol Neurotol 2017; 38 (05) 730-736
• 23 Ahmed MF, Goebel JA, Sinks BC. Caloric test versus rotational sinusoidal harmonic acceleration and step-velocity tests in patients with and without suspected peripheral vestibulopathy. Otol Neurotol 2009; 30 (06) 800-805
• 24 Fife TD, Colebatch JG, Kerber KA. et al. Practice guideline: cervical and ocular vestibular evoked myogenic potential testing: report of the guideline development, dissemination, and implementation subcommittee of the American Academy of Neurology. Neurology 2017; 89 (22) 2288-2296
• 25 Kerber KA, Schweigler L, West BT, Fendrick AM, Morgenstern LB. Value of CT scans in ED dizziness visits: analysis from a nationally-representative sample. Am J Emerg Med 2010; 28 (09) 1030-1036
• 26 Saber Tehrani AS, Kattah JC, Mantokoudis G. et al. Small strokes causing severe vertigo: frequency of false-negative MRIs and nonlacunar mechanisms. Neurology 2014; 83 (02) 169-173
• 27 Lee H, Kim B-K, Park H-J, Koo J-W, Kim J-S. Prodromal dizziness in vestibular neuritis: frequency and clinical implication. J Neurol Neurosurg Psychiatry 2009; 80 (03) 355-356
• 28 Fishman JM, Burgess C, Waddell A. Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis). Cochrane Database Syst Rev 2011; (05) CD008607
• 29 Tokle G, Mørkved S, Bråthen G. et al. Efficacy of vestibular rehabilitation following acute vestibular neuritis: a randomized controlled trial. Otol Neurotol 2020; 41 (01) 78-85
• 30 Choi J-H, Oh EH, Park M-G. et al. Early MRI-negative posterior circulation stroke presenting as acute dizziness. J Neurol 2018; 265 (12) 2993-3000
• 31 Sumer M, Ozdemir I, Erturk O. Progression in acute ischemic stroke: frequency, risk factors and prognosis. J Clin Neurosci 2003; 10 (02) 177-180
• 32 Baloh RW. Vestibular migraine I: mechanisms, diagnosis, and clinical features. Semin Neurol 2020; 40 (01) 76-82
• 33 Byun YJ, Levy DA, Nguyen SA, Brennan E, Rizk HG. Treatment of vestibular migraine: a systematic review and meta-analysis. Laryngoscope 2020
• 34 Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev 2014; (12) CD003162
• 35 Choi SY, Jang J-Y, Oh EH. et al. Persistent geotropic positional nystagmus in unilateral cerebellar lesions. Neurology 2018; 91 (11) e1053-e1057
• 36 Kim JS, Oh S-Y, Lee S-H. et al. Randomized clinical trial for geotropic horizontal canal benign paroxysmal positional vertigo. Neurology 2012; 79 (07) 700-707
• 37 De Schutter E, Adham ZO, Kattah JC. Central positional vertigo: a clinical-imaging study. Prog Brain Res 2019; 249: 345-360
• 38 Hannigan IP, Welgampola MS, Watson SRD. Dissociation of caloric and head impulse tests: a marker of Meniere's disease. J Neurol 2021; 268 (02) 431-439
• 39 Limviriyakul S, Luangsawang C, Suvansit K, Prakairungthong S, Thongyai K, Atipas S. Video head impulse test and caloric test in definite Ménière's disease. Eur Arch Otorhinolaryngol 2020; 277 (03) 679-686
• 40 Crowson MG, Patki A, Tucci DL. A systematic review of diuretics in the medical management of Ménière's disease. Otolaryngol Head Neck Surg 2016; 154 (05) 824-834
• 41 Adrion C, Fischer CS, Wagner J, Gürkov R, Mansmann U, Strupp M. BEMED Study Group. Efficacy and safety of betahistine treatment in patients with Meniere's disease: primary results of a long term, multicentre, double blind, randomised, placebo controlled, dose defining trial (BEMED trial). BMJ 2016; 352: h6816
• 42 Wright T. Menière's disease. BMJ Clin Evid 2015; 0505
• 43 Kitahara T. Evidence of surgical treatments for intractable Meniere's disease. Auris Nasus Larynx 2018; 45 (03) 393-398
• 44 Eschlböck S, Wenning G, Fanciulli A. Evidence-based treatment of neurogenic orthostatic hypotension and related symptoms. J Neural Transm (Vienna) 2017; 124 (12) 1567-1605
• 45 Gibbons CH, Schmidt P, Biaggioni I. et al. The recommendations of a consensus panel for the screening, diagnosis, and treatment of neurogenic orthostatic hypotension and associated supine hypertension. J Neurol 2017; 264 (08) 1567-1582
• 46 Staab JP. Persistent postural-perceptual dizziness. Semin Neurol 2020; 40 (01) 130-137
• 47 Masaki Y. The prevalence of superior canal dehiscence syndrome as assessed by temporal bone computed tomography imaging. Acta Otolaryngol 2011; 131 (03) 258-262
• 48 Berning AW, Arani K, Branstetter IV BF. Prevalence of superior semicircular canal dehiscence on high-resolution CT imaging in patients without vestibular or auditory abnormalities. AJNR Am J Neuroradiol 2019; 40 (04) 709-712
• 49 Williamson RA, Vrabec JT, Coker NJ, Sandlin M. Coronal computed tomography prevalence of superior semicircular canal dehiscence. Otolaryngol Head Neck Surg 2003; 129 (05) 481-489
• 50 Ward BK, Carey JP, Minor LB. Superior canal dehiscence syndrome: lessons from the first 20 years. Front Neurol 2017; 8: 177
• 51 Multichannel Vestibular Implant Early Feasibility Study - Full Text View - ClinicalTrials.gov [Internet]. [cited February 27, 2020]. Accessed December 29, 2020 at: https://clinicaltrials.gov/ct2/show/NCT02725463
• 52 Boutros PJ, Schoo DP, Rahman M. et al. Continuous vestibular implant stimulation partially restores eye-stabilizing reflexes. JCI Insight [Internet]. [cited April 28, 2020];4(22). Accessed December 29, 2020 at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6948863/
• 53 Choi K-D, Shin H-Y, Kim JS. et al. Rotational vertebral artery syndrome: oculographic analysis of nystagmus. Neurology 2005; 65 (08) 1287-1290
• 54 Strickland BA, Pham MH, Bakhsheshian J, Russin JJ, Mack WJ, Acosta FL. Bow Hunter's syndrome: surgical management (video) and review of the literature. World Neurosurg 2017; 103: 953.e7-953.e12
• 55 Strupp M, Lopez-Escamez JA, Kim J-S. et al. Vestibular paroxysmia: diagnostic criteria. J Vestib Res 2016; 26 (5-6): 409-415