3-20
Symptom: Dizziness
CPT Brooks Morelock, MC, USAIntroduction: The complaint of dizziness is extremely vague and must be clarified. When a patient presents
with dizziness, the examiner must ascertain whether the person is describing an alteration of consciousness
(see Symptome: Syncope), an alteration of balance, a sensation of motion, or a feeling of lightheadedness
that accompanies standing up. It should become readily apparent that the etiology of dizziness may involve in
the inner ear, the central nervous system or a systemic disorder.
Subjective: Symptoms
Focused History: Does the patient have a prior history that can account for recurrent dizziness such
as Meniere’s disease or vertigo? Duration How long has the patient had symptoms? (acute symptoms
likely a self-limited illness such as otitis media or labyrinthitis. Chronic symptoms suggest either anatomic
abnormalities, such as acoustic neuroma, or chronic illness such as Meniere’s) Illness Has the patient been
ill, especially any upper respiratory illnesses? (recent URI can lead to vertigo through otitis media, either
serous or purulent; labyrinthitis or benign paroxysmal vertigo.) Fullness Has the patient been experiencing
ear pain / fullness? (can be associated with otitis media.) Trauma Has the patient been exposed to any
direct trauma to the ear or barotrauma? (Can result in serous otitis media.) Has the patient been flying or
diving recently? (possible decompression sickness–see Diving Medicine) Hearing/Ringing Does the patient
have a persistent ringing (tinnitus) in their ears? If so, do they also have a hearing loss? (the combination
makes Meniere’s more likely). Spinning Does the patient have a sensation of motion/spinning? If so, does
head movement bring it on? (classic symptoms for benign paroxysmal vertigo, which may be accompanied
by vomiting.) Walking Does the patient have difficulty walking? If so, do they feel dizzy when this happens?
(abnormal gait without dizziness is most likely ataxia (difficulty walking), a motor control problem) Falling
Does the patient constantly fall toward the same direction? (An anatomic abnormality [i.e., tumor] in the
middle ear will classically cause the patient to fall toward the affected side.)
Objective: Signs
Using Basic Tools: Vital signs: Low blood pressure (or a change with standing of >20mm Hg systolic)
suggests possible dehydration causing pre-syncope due to volume depletion. fever: possible inner ear
infection.
Ear Exam (otoscope): Tympanic membrane (TM) normal: typical finding that only rules out vertigo caused
by infection. TM injected, loss of light reflex, +/- purulent fluid in middle ear: purulent otitis media can
cause vertigo by stimulating of the vestibular apparatus. TM bulging, clear fluid in middle ear: suggests
serous otitis media.
Neurologic: Dix-Hallpike Maneuver*- positive symptom reproduction and rotatory nystagmus – vertigo.
Abnormal neuro exam: Possible CNS dysfunction- consider evacuation.
- Dix-Hallpike Maneuver: Have the patient sit, so that when lying supine, the head extends over the end of the
table. Instruct the patient to keep their eyes open and to stare at the examiner’s nose during the test. To test
the left posterior canal, have the patient turn his head 45° to the left. Keeping the head in this position, lie the
patient down rapidly until the head is dependent and extended below the table. In each position, observe the
eyes closely for up to 40 seconds for development of nystagmus. Return the patient to the upright position.
To test the right posterior canal, repeat maneuver with the head turned 45° to the right side.
Assessment:
Differential Diagnosis
Meniere’s Disease - a chronic disorder resulting in decreased hearing acuity over long duration, accompanied
by multiple exacerbations of vertigo and tinnitus.
Labyrinthitis - causes dizziness and a decrease in hearing acuity. This can be due to bacterial or viral
infection.
Benign Positional Vertigo (BPV) / Benign Paroxysmal Positional Vertigo (BPPV) - an acute spinning sensation
brought on with head movement, and associated with a rotatory nystagmus on physical exam. There is no
change in the patient’s hearing. The vertigo and nystagmus can be elicited by Dix-Hallpike Maneuvers*. The