Physicians should pay particular attention to physical findings of the neurologic, head and neck, and cardiovascular systems. The cranial nerves should be examined for signs of palsies, sensorineural hearing loss, and nystagmus.
Vertical nystagmus is 80 percent sensitive for vestibular nuclear or cerebellar vermis lesions. Patients with peripheral vertigo have impaired balance but are still able to walk, whereas patients with central vertigo have more severe instability and often cannot walk or even stand without falling. In one study, 22 it was only 19 percent sensitive for peripheral vestibular disorders and did not correlate with more serious causes of dizziness not limited to vertigo such as drug-related dizziness, seizure, arrhythmia, or cerebrovascular events.
The Dix-Hallpike maneuver Figure 2 1 , 3 , 19 may be the most helpful test to perform on patients with vertigo. It has a positive predictive value of 83 percent and a negative predictive value of 52 percent for the diagnosis of BPPV. To perform the Dix-Hallpike maneuver, the patient initially sits upright. The examiner should warn the patient that the maneuver may provoke vertigo. After a two- to second latent period, the onset of torsional upbeat or horizontal nystagmus denotes a positive test for benign paroxysmal positional vertigo.
The episode can last 20 to 40 seconds. Nystagmus changes direction when the patient sits upright again. Information from references 1 , 3 , and Hyperventilation for 30 seconds may assist in ruling out psychogenic causes of vertigo associated with hyperventilation syndrome.
The tympanic membranes should be examined for vesicles i. Orthostatic changes in systolic blood pressure e. Laboratory tests such as electrolytes, glucose, blood counts, and thyroid function tests identify the etiology of vertigo in fewer than 1 percent of patients with dizziness. Physicians should consider neuroimaging studies in patients with vertigo who have neurologic signs and symptoms, risk factors for cerebrovascular disease, or progressive unilateral hearing loss.
In patients with isolated vertigo who also were at risk for cerebrovascular disease, 25 percent had caudal cerebellar infarcts. Neuroimaging studies can be used to rule out extensive bacterial infections, neoplasms, or developmental abnormalities if other symptoms suggest one of those diagnoses.
Conventional radiographs or cross-sectional imaging procedures may aid in the diagnosis of cervical vertigo i. Not all patients with vertigo need to be referred to a subspecialist. Family physicians should consider referral to the appropriate subspecialist e. Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. Address correspondence to Ronald H. Labuguen, M. Grand Ave. Reprints are not available from the author. The author thanks Lyndee Knox, Ph.
A systematic review of vertigo in primary care. Br J Gen Pract. Causes of persistent dizziness. A prospective study of patients in ambulatory care. Ann Intern Med. Derebery MJ. The diagnosis and treatment of dizziness. Med Clin North Am. Brandt T, Bronstein AM. Cervical vertigo. J Neurol Neurosurg Psychiatry.
Diagnosis and treatment of the dizzy patient. Hospital Physician. Solomon D. Distinguishing and treating causes of central vertigo.
Otolaryngol Clin North Am. Symptoms of vertigo in general practice: a prospective study of diagnosis. Drozd CE. Acute vertigo: peripheral versus central etiology. Nurse Pract. Baloh RW. The dizzy patient. Postgrad Med. Evaluating dizziness. Am J Med. Evans JG. Transient neurological dysfunction and risk of stroke in an elderly English population: the different significance of vertigo and non-rotatory dizziness.
Age Ageing. Rosenberg ML, Gizzi M. Neurootologic history. The rational clinical examination. Does this dizzy patient have a serious form of vertigo? Differentiating between peripheral and central causes of vertigo. Otolaryngol Head Neck Surg. Diagnostic criteria for central versus peripheral positioning nystagmus and vertigo: a review. Acta Otolaryngol. Berkowitz BW. Matutinal vertigo. Clinical characteristics and possible management. Arch Neurol. Benign positional vertigo: incidence and prognosis in a population-based study in Olmsted County, Minnesota.
Mayo Clin Proc. Kentala E, Rauch SD. A practical assessment algorithm for diagnosis of dizziness. Quickly sit the patient upright with their head tilted to the affected side. This manoeuvre should not be performed in patients with neck injury, carotid stenosis and heart disease 1 Acute labyrinthitis The inner ear is composed of the bony and the membranous labyrinth. Vestibular neuronitis VN is caused by inflammation of the vestibular nerve.
In these cases, referral to a neurologist is recommended. A careful history is required to elicit features of central or peripheral causes of vertigo. Physical examination involves a neurological, cardiovascular, eye and ear examination. Treatment is specific to the cause of vertigo. Can GPs diagnose benign positional paroxysmal vertigo and does the Epley manoeuvre work in primary care? Br J Gen Pract ;60 — Initial evaluation of vertigo. Am Fam Physician ;73 2 — Dizziness: A diagnostic approach.
Am Fam Physician ;82 4 — Vertigo — Part 1 — Assessment in general practice. Aust Fam Physician. Central vestibular pathways: Eye, head, and body reflexes. Sunderland, MA: Sinauer Associates, Vestibular system anatomy. New York: Medscape, Search PubMed A delicate balance: Managing vertigo in general practice.
Best Practice Journal ;46 Sep — Search PubMed Paine M. Dealing with dizziness. Aust Prescr ;28 1 — Acute vertigo: Peripheral versus central etiology. Nurse Pract ;24 4 — The dizzy patient. Postgrad Med ;—64, — Differentiating between peripheral and central causes of vertigo. Otolaryngol Head Neck Surg ; 1 — The quick component of nystagmus.
J Physiol ;97 1 :8— Search PubMed Karatas M. Vascular vertigo: Epidemiology and clinical syndromes. Neurologist ;17 1 :1— Search PubMed Mathews T. Peripheral vertigo in general practice. Continuing Medical Education ;— Treament of vertigo. Am Fam Physician ;71 6 — Labyrinthitis treatment and management. A stepwise approach. Medicine Today. Updated Vestibular neuronitis: A review of a common cause of vertigo in general practice.
Br J Gen Pract ;43 — A directed approach to the dizzy patient. Ann Emerg Med ;— Vertigo and hearing loss. Am J Neuroradiol ;30 8 — The diagnostic value of imaging the patient with dizziness.
A Bayesian approach. Arch Neurol 12 — Vertigo-diagnosis and management in primary care. BJMP ;3 4 :a Search PubMed. Back to search results. Focus General practice encounters with men. Explore these free sample topics:. Transverse Myelitis. Acetaminophen Poisoning. Arthritis, Juvenile Idiopathic Rheumatoid. Abdominal pain, left lower quadrant. True labyrinthitis is rare. There's more to see -- the rest of this entry is available only to subscribers. We're glad you have enjoyed 5-Minute Clinical Consult!
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Renew my subscription. Tags Type your tag names separated by a space and hit enter. Labyrinthitis is a topic covered in the 5-Minute Clinical Consult. Clarify symptoms by giving options of alternative descriptions such as light-headedness, disequilibrium, room-spinning vertigo, or imbalance.
Hearing loss and duration of symptoms can help narrow the differential diagnosis in patients with vertigo.
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