Evaluation of dizziness

vertigo on rolling over in bed or looking up, which lasts for seconds

Dix-Hallpike test: diagnostic of BPPV, typically demonstrating nystagmus and symptoms that are delayed by about 15 seconds, peak in 20-30 seconds, and then decay with complete resolution of the episode of vertigo; supine lateral head turns: similar to the Dix-Hallpike maneuver, a positive test is noted when the patient experiences vertigo with nystagmus.

spontaneous vertigo attacks (each lasting 20 minutes to 12 hours) with documented low- to mid-frequency sensorineural hearing loss in the affected ear before, during, or after one of the episodes of vertigo, with fluctuating aural symptoms (hearing loss, tinnitus, or ear fullness) in the affected ear

usually normal, Romberg’s test may be positive, may have horizontal and/or rotatory nystagmus which is suppressed by fixation

acute onset of vertigo with nausea and vomiting, lasting days but without hearing loss; single episodes frequently recur; symptoms exacerbated by changes in head position

acute episode: may be nystagmus to the affected side, head impulse test will be abnormal (due to loss of the vestibulo-ocular reflex); loss of balance; between episodes of vertigo exam may be normal

acute onset of vertigo with nausea and vomiting lasting days; associated hearing loss with or without tinnitus; may be a preceding history of acute otitis media

nystagmus is usually horizontal, and severity improves as the illness resolves; patients may have difficulty walking; unilateral sensorineural hearing loss demonstrated with Rinne and Weber tuning fork tests; ear exam may demonstrate evidence of acute otitis media (bulging, erythematous, or opaque tympanic membrane); postaural redness or swelling may occur if mastoiditis complicates the infection

personal history or family history of migraine; vertigo with or without headaches; symptoms variable including true episodic vertigo, movement-provoked disequilibrium, lightheadedness, symptoms similar to benign positional paroxysmal vertigo, photophobia, phonophobia, or other auras, or symptoms similar to Meniere disease; associated symptoms of nausea and fatigue; symptoms might last minutes to days

usually normal, may have positional nystagmus and positive Romberg test in acute attack[118]Li V, McArdle H, Trip SA. Vestibular migraine. BMJ. 2019 Jul 3;366:l4213. https://www.bmj.com/content/366/bmj.l4213.long http://www.ncbi.nlm.nih.gov/pubmed/31270067?tool=bestpractice.com

variable depending on specific cause but may include generalized weakness, giddiness, headache, blurred vision, and diaphoresis; may be paresthesia, nausea, and vomiting; patients have a sensation of an impending loss of consciousness

vasovagal attack: hypotension and bradycardia during attack; cardiopulmonary disease: altered cardiac rhythm, murmurs, evidence of cardiac failure

dizziness on standing from a lying or sitting position, episodes are usually transient, may be a history of hypotension, antihypertensive medication use, dehydration, autonomic dysfunction (e.g., with Parkinson disease, multiple system atrophy, diabetic autonomic neuropathy); if associated with autonomic dysfunction may also have dizziness when standing upright for prolonged periods, swimming, or running and may complain of feeling "spacey" or "foggy" without vertigo during exertion; may be a history of bariatric surgery

drop in systolic BP by 20 mmHg or diastolic BP by 10 mmHg within three minutes of standing from a lying position

dizziness and palpitations on standing from a lying or sitting position, episodes are usually transient; may be fatigue, nausea, presyncope or syncope, more common in women and girls between 12-50 years of age

increase in heart rate on standing (and with tilt table study) by 30 bpm or >120 bpm and associated postural symptoms; lack of orthostatic hypotension; absence of other conditions that may cause orthostatic hypotension, such as dehydration, a primary cardiac cause, an endocrine disorder, or a nervous system disorder[60]Bogle JM, Goodman BP, Barrs DM. Postural orthostatic tachycardia syndrome for the otolaryngologist. Laryngoscope. 2017 May;127(5):1195-8. http://www.ncbi.nlm.nih.gov/pubmed/27578452?tool=bestpractice.com

most commonly occurs in people with a known history of diabetes mellitus; often dizziness may coincide with episodes of hypoglycemia where patient feels ill, clammy, generally weak; may be a preceding peripheral vestibular disorder and prolonged symptoms, particularly with associated peripheral neuropathy (associated numbness in feet and legs and history of painless injuries)

may be signs of peripheral neuropathy including numbness and presence of painless injuries

acute intoxication: patients report feeling "high," dizzy, and intoxicated

smell of alcohol on the breath, disorientation, abnormal gait

history of aminoglycoside antibiotics, cisplatin, or other drugs that may cause dizziness (e.g., antihypertensive or antiarrhythmic medication, diuretics, antipsychotic or antiparkinsonian medication, opioids, phosphodiesterase inhibitors, or anesthetic medication); may be hearing loss and tinnitus with aminoglycosides and cisplatin

may be orthostatic hypotension on exam if taking antihypertensive, antipsychotic or antiparkinsonian medication, opioids, or phosphodiesterase inhibitors

dizziness associated with a current or previous COVID-19 infection, typical symptoms are dry cough, fever, and dyspnea; other common symptoms include anorexia, myalgia, and sore throat; may be travel history to an affected area or close contact with a suspected or confirmed case in the 14 days prior to symptom onset

may have fever and/or dyspnea; patients with pneumonia or respiratory distress syndrome may have inspiratory crackles, rales, and/or bronchial breathing; patients with respiratory distress syndrome may have tachycardia, tachypnea, or cyanosis accompanying hypoxia

malodorous ear discharge and hearing loss, with or without tinnitus; less commonly vertigo, otalgia, altered taste, or facial weakness

otoscopy reveals crust or keratin in the attic (upper part of the middle ear), the pars flaccida, or the pars tensa (usually posterior superior aspect), with or without perforation of the tympanic membrane; fistula test may be positive

history of episodes of vertigo associated with sound or pressure such as coughing, sneezing, straining, or sudden loud noise and hyperacusis; a feeling of the affected ear being blocked; autophony; may be preceding history of trauma

upward and torsional nystagmus evoked by Tullio (loud noise) and Hennebert (altered middle-ear pressure) tests

may have a history of surgery such as stapes surgery, head trauma or barotrauma; paroxysmal vertigo, imbalance, and hearing loss with or without tinnitus

may have a positive fistula test

Five diagnostic criteria must be satisfied to make the diagnosis: 1) History of dizziness, unsteadiness, or nonspinning vertigo on most days for ≥3 months. 2) Symptoms occurring without provocation but worse with upright posture, active or passive motion, or exposure to moving stimuli. 3) Precipitated by conditions that cause vertigo, neurologic or medical illness, or psychological distress. 4) Symptoms cause significant distress or functional impairment. 5) Symptoms not better explained by another disorder.

physical exam normal

typically unilateral hearing loss, dizziness, or vertigo and tinnitus

spontaneous nystagmus may be present

vertigo as an initial symptom (5%) or at some point during their disease (50%); prolonged spontaneous attacks of vertigo may be similar to vestibular neuritis; variety of symptoms such as dizziness, diplopia, and altered gait

variety of neurologic findings, such as nystagmus, ataxia, and cranial nerve palsies

sudden intense vertigo, nausea, and vomiting, dysarthria, unilateral limb weakness, headache, diplopia

nystagmus present and may be bilateral or vertical (suggesting a central cause), head impulse test is negative, patients usually cannot stand without support; patients may have gait and limb ataxia, facial numbness, Horner syndrome, diplopia

episodic vertigo lasting between 30 seconds and 15 minutes and typically starting after abruptly standing or turning the head; associated with diplopia, dysarthria, ataxia, drop attack, and clumsiness of the extremities; may have risk factors for stroke such as hypertension, hyperlipidemia, diabetes, smoking, or heart disease

usually normal

occipital headache, dizziness, unsteadiness, and hearing loss, but may be asymptomatic[44]Guerra Jiménez G, Mazón Gutiérrez Á, Marco de Lucas E, et al. Audio-vestibular signs and symptoms in Chiari malformation type i. Case series and literature review [in English, Spanish]. Acta Otorrinolaringol Esp. 2015 Jan-Feb;66(1):28-35. http://www.ncbi.nlm.nih.gov/pubmed/25195076?tool=bestpractice.com

may be downbeat nystagmus, most prominent on lateral gaze; positional testing may precipitate dizziness with downbeat nystagmus

double vision, abnormal balance, facial or limb numbness, prolonged vertigo lasting several days

abnormal eye movements; ipsilateral Horner syndrome; diplopia; ipsilateral limb ataxia; truncal ataxia; dysphagia and hoarseness; loss of pain and temperature sensation of the ipsilateral face and contralateral trunk

history of head trauma (e.g., a fall, an assault, or a motor vehicle accident), vertigo, disequilibrium, tinnitus, pressure, headache, diplopia

evidence of fluid or blood in the middle ear, evidence of a temporal bone fracture (e.g., mastoid and periorbital ecchymosis, abnormal neurologic findings, cerebrospinal fluid otorrhea).

more likely to be a young adult or trauma patient; dizziness, headache, and neck pain; may be history of predisposing factors, such as hypertension, recent infection, connective tissue disorder (e.g., Ehlers-Danlos syndrome, Marfan syndrome, osteogenesis imperfecta, fibromuscular dysplasia)​

dysarthria, visual field deficits, ataxia

history of cancer of the ovary, breast, or lung, or history of Hodgkin lymphoma; dizziness, nausea and vomiting, gait instability, altered speech, and dysphagia

nystagmus, ocular dysmetria, abnormalities of pursuit, saccadic oscillations, and an ataxic gait ± features of the associated cancer

often obese; headaches and transient episodes of poor vision; dizziness and tinnitus

papilledema on fundoscopy; some have bilateral 6th nerve palsy

history of abnormal balance, urinary incontinence, and cognitive dysfunction

ataxic gait, cognitive dysfunction

swinging, swaying, unsteadiness, and disequilibrium after exposure to motion (e.g., long voyage, air travel); symptoms may last for hours, months, or years; symptoms occur after disembarking; not associated with nausea or vomiting

usually normal

a variety of symptoms such as rocking, floating, or swimming sensations; symptoms may worsen with stress or fatigue

anxious, may be hyperventilating, normal clinical balance tests

dizziness on standing and walking; may demonstrate anxiety reactions and avoidance behavior to specific stimuli; may be history of panic disorder with agoraphobia, personality disorders, or generalized anxiety; inappropriate or excessive anxiety or fear

normal clinical balance tests

history of SLE, photosensitive rash, fatigue, weight loss, alopecia, joint pain, symptoms of vertigo ± hearing loss

clinical features of SLE: malar rash, discoid rash, oral ulcers, hypertension, peripheral edema, retinal vasculitis

history of photophobia, ocular discomfort, lacrimation, fluctuating hearing loss, imbalance or vertigo

ocular redness

dizziness or vertigo, hearing loss, facial weakness; may have symptoms of nasal involvement with excessive nasal crusting, epistaxis or nasal discharge; lower respiratory tract symptoms of dyspnea, cough, hemoptysis or chest pain; fever, night sweats, anorexia, weight loss, malaise; neurologic symptoms of numbness, focal weakness or headache; ocular symptoms of redness, pain, diplopia, visual blurring; arthralgia, myalgia or joint swelling; purpuric, nodular, hemorrhagic or ulcerative skin lesions

serous otitis media (tympanic membrane retracted or concave, with impaired mobility), facial palsy, nasal lesions or upper respiratory tract mucosal bleeding, ulceration or crusting; may have septal perforation or saddle nose deformity; may have crackles, focal dullness to percussion or rhonchi; fever; mononeuritis multiplex; red eye, proptosis, reduced visual acuity, retinal exudates and hemorrhage; palpable purpura, cutaneous nodules, hemorrhagic and ulcerative skin lesions; joint tenderness or swelling, muscle weakness

recurrent genital and oral ulceration, eye pain, photophobia, blurred vision, headache, hearing impairment, tinnitus, dizziness

genital ulcers, oral ulcers, red eye, acne lesions, erythema nodosum, superficial thrombophlebitis

may be history of suspected accidental exposure from residential boilers, central heating systems, cookers, fireplaces, and chimneys; often nonspecific symptoms, such as vertigo, headaches, impaired concentration, presyncope, angina, shortness of breath, nausea and vomiting, fatigue[108]Hampson NB, Piantadosi CA, Thom SR, et al. Practice recommendations in the diagnosis, management, and prevention of carbon monoxide poisoning. Am J Respir Crit Care Med. 2012 Dec 1;186(11):1095-101. http://www.ncbi.nlm.nih.gov/pubmed/23087025?tool=bestpractice.com

may be normal; flushed cheeks, tachycardia, hypotension

history of a surgical procedure (e.g., stapedectomy, middle-ear surgery, or cochlear implantation)

positive fistula test

hearing loss or vertigo with or without other variable symptoms (e.g., malaise, myalgia, rash); late neurosyphilis: may present with hearing loss, fluctuating hearing, or dizziness or vertigo with or without other variable symptoms (e.g., personality change, altered mood, loss of anal and bladder sphincter control)

variable signs, including lymphadenopathy, rash, mucosal ulceration with or without signs of more specific organ involvement (e.g., uveitis, meningism, seizures, nephrotic syndrome); late neurosyphilis: signs of tabes dorsalis (e.g., ataxia, Argyll-Robertson pupils, areflexia, loss of vibration/proprioception, positive Romberg sign), may have signs of memory impairment, confusion, tremor