Evaluation of a Dizzy Patient

Presenter: Dr. Joel A. Goebel M.D.

AAO-HNS 2016 - 9/21

• • As with most things in medicine, history is KEY

  • If a patient has vertigo, you can probably do something about it

  • History

    • Time (general guidelines)

      • Sec - BPPV

      • Mins - Meniere's (10-15 mins to 1hr), migraines (variable), TIA (10-15 mins + other symptoms)

      • Hours - Migraines, neuritis (i.e. Scarpa's ganglion - fever, blisters, HSV-1, much more common than labrynthitis)

    • Signx/Sx

      • i.e. vertigo x 15 mins with arm movement difficulty - think TIA

      • relation to head movement

        • Central: OK to move head

        • Peripheral: Can't/don't want to move head

      • +syncope? --> Not just labyrinth, likely neurocardiogenic

      • Fullness - Meniere's

      • Loud noise --> dizziness? - think SCCD

      • Vertigo x hrs + n/v --> think vestibular neuritis. If +HL, think labyrinthitis

    • Exam

      • VOR exam

      • VSR

      • Central OM exam

      • Posture

      • Gait

      • Look up HINT Exam, Stroke 2009

  • Pearls

    • Nystagmus

      • Central up/downbeat --> brainstem, call neurology

      • Changes size with gaze --> cerebellum

    • Internuclear opthalmoplegia (INO) --> demyelination disease

    • Head impulse test

      • + results in the direction you turn indicated that is the bad side

    • RULE OUT stroke in acute vertigo

      • Look for skew deviation by covering one eye and the uncovering it, make sure their eye doesn't shift

    • Equipment

      • Tuning forks

        • 512 - hearing

        • 256 - good for SCCD - freq most affected by air-bone gap

        • 128 - out of ankle to gauge vibration sense and rule out peripheral neuropathy

      • M glasses (U. of Munich)

      • Air cushion