Investigation

• it is important to differentiate vertigo from non-rotatory dizziness (presyncope, disequilibrium, lightheadedness). Patients should be asked whether “he/she felt light headed or felt as if the world was spinning around as though he/she had just gotten off a playground roundabout” during a dizzy spell (1)
• the history is all important and may give a quite good indication of the cause of vertigo. Remember that general medical causes such as anaemia, hypotension and hypoglycaemia may present with dizziness.
• important points in the history:
  • onset - ask about specific events such as flying, trauma
  • duration (common causes):
    • seconds
      • benign positional vertigo
    • hours
      • Menieres disease
    • weeks
      • labyrinthitis
      • post-head trauma
      • vestibular neuronitis
    • years
      • may be psychogenic
  • associated auditory symptoms - rare in primary CNS lesion
  • other associated symptoms
    • nausea and vomiting in a vestibular cause
    • neurologic symptoms such as visual disturbance, dysarthria in a central lesion
• examination and tests relevant for the investigating vertigo include:
  • examination of ear drums (Otoscopy/ Pneumatic otoscopy) for:
    • vesicles ( herpes zoster oticus [Ramsay Hunt syndrome])
    • cholesteatoma
  • tuning fork tests for hearing loss
  • cranial nerve examination
    • cranial nerves should be examined for signs of :
      • palsies
      • sensorineural hearing loss
      • nystagmus (2)
  • Hennebert's sign (2)
    • vertigo or nystagmus caused by pushing on the tragus and external auditory meatus of the affected side
    • indicates the presence of a perilymphatic fistula.
  • gait tests:
    • Romberg's sign
      • not particularly useful in the diagnosis of vertigo (2)
    • heel to toe walking test
    • Unterberger's stepping test
  • Dix-Hallpike manoeuvre (2)
  • the most helpful test to perform on patients with vertigo (2)
  • head impulse test/head thrust test
    • useful in recognizing acute vestibulopathy (1)
  • caloric tests
  • special auditory tests
    • audiometry helps establish the diagnosis of Ménière's disease (2)

Note:

• The Hallpike maneuver and the head impulse test are used in primary care to help identify vestibular as opposed to brainstem diseases (1)

Reference:

• (1) Barraclough K, Bronstein A. Vertigo. BMJ. 2009;339:b3493
• (2) Ronald H. Labuguen. Initial Evaluation of Vertigo. Am Fam Physician 2006;73:244-51, 254