Curriculum · Neurology
Approach to dizziness
What it is
Dizziness is a word that patients use for more than one thing, so the most important and first thing to ask is what the patient means by it.
- Do you feel lightheaded, or like you are going to pass out? If yes, it is presyncope. SOB or CP alongside it points the same way.
- Does it feel like the room is spinning? If yes, it is likely vertigo.
- Do you feel unsteady on your feet? If yes, it is likely vertigo.
Once the word is clear, the next split is central against peripheral. An acute picture with no neighborhood signs but with tinnitus and hearing loss points to the peripheral arm, where the focus is symptom control and specific maneuvers based on diagnosis. A chronic picture with neighborhood signs but no tinnitus and no hearing loss points to the organic and dementia arm, where the focus is imaging of the posterior fossa with MRI.
How it presents
Vertigo is the sensation that the room is spinning, or that the patient is spinning.
- Vestibular neuronitis comes after a recent viral infection and gives recurrent vertigo attacks lasting hours or days, with no hearing loss and no other auditory symptoms. Horizontal nystagmus is seen on examination.
- Labyrinthitis is an infection of the membranous labyrinth. It affects the vestibular nerve, which gives the vertigo, and the cochlear end organs, which give the auditory symptoms of tinnitus and hearing loss. The hearing loss can be uni- or bilateral. It is usually viral and occurs after a viral upper respiratory tract infection. The vertigo is made worse by movement but is not triggered by it.
- Benign paroxysmal positional vertigo gives very short episodes, only 10-20 seconds, and they are triggered by head movement.
- Meniere's disease gives the same three symptoms of vertigo, tinnitus and hearing loss, but in episodes that last minutes to hours rather than continuously, and aural fullness may be reported with them.
- A cerebellar stroke can open with severe dizziness and difficulty walking in a straight line, with headache, and with no recent illness behind it.