Using the Physical Examination to Diagnose Patients With Acute Dizziness and Vertigo

Jonathan A. Edlow, MD; David Newman-Toker, MD, PHD

Disclosures

J Emerg Med. 2016;50(4):617-628. 

In This Article

Abstract and Introduction

Abstract

Background: Emergency department (ED) patients who present with acute dizziness or vertigo can be challenging to diagnose. Roughly half have general medical disorders that are usually apparent from the context, associated symptoms, or initial laboratory tests. The rest include a mix of common inner ear disorders and uncommon neurologic ones, particularly vertebrobasilar strokes or posterior fossa mass lesions. In these latter cases, misdiagnosis can lead to serious adverse consequences for patients.

Objective: Our aim was to assist emergency physicians to use the physical examination effectively to make a specific diagnosis in patients with acute dizziness or vertigo.

Discussion: Recent evidence indicates that the physical examination can help physicians accurately discriminate between benign inner ear conditions and dangerous central ones, enabling correct management of peripheral vestibular disease and avoiding dangerous misdiagnoses of central ones. Patients with the acute vestibular syndrome mostly have vestibular neuritis, but some have stroke. Data suggest that focused eye movement examinations, at least when performed by specialists, are more sensitive for detecting early stroke than brain imaging, including diffusion-weighted magnetic resonance imaging. Patients with the triggered episodic vestibular syndrome mostly have benign paroxysmal positional vertigo (BPPV), but some have posterior fossa mass lesions. Specific positional tests to provoke nystagmus can confirm a BPPV diagnosis at the bedside, enabling immediate curative therapy, or indicate the need for imaging.

Conclusions: Emergency physicians can effectively use the physical examination to make a specific diagnosis in patients with acute dizziness or vertigo. They must understand the limitations of brain imaging. This may reduce misdiagnosis of serious central causes of dizziness, including posterior circulation stroke and posterior fossa mass lesions, and improve resource utilization.

Introduction

Patients with dizziness account for just over 3% of all emergency department (ED) visits.[1] Because of the wide differential diagnosis, these individuals can be difficult to diagnose. Although most have benign vestibular problems, or general medical causes that are often apparent from the clinical context, co-symptoms, and vital signs, some have posterior circulation stroke and other serious central nervous system (CNS) causes. The traditional diagnostic paradigm is based on symptom quality—"what do you mean dizzy?" According to this system, a patient with "vertigo" has a different list of possible causes than those who endorse "lightheadedness".[2]

During the last decade, mounting research suggests that this paradigm, based on data published more than 40 years ago, is faulty and that the specific word that the patient endorses is not diagnostically meaningful.[3,4] A new paradigm based on the timing and triggers of dizziness has been proposed.[4–7] According to this new paradigm, patients are grouped into major categories (Table 1) based on the timing and trigger pattern of their dizziness symptoms.[8] Understanding these three clinical groups is key to the use of the physical examination.

Patients with the acute vestibular syndrome have monophasic acute dizziness that begins abruptly or very rapidly and persists continuously for days. Although they will usually feel less symptomatic when not moving, they are still dizzy at rest. The critical distinction is that their dizziness may be exacerbated (i.e., from an abnormal baseline) by movement but it is not triggered (i.e., from a normal baseline) by movement. Patients with the triggered episodic vestibular syndrome (t-EVS) have repetitive episodes of dizziness that are triggered by some event. They are completely asymptomatic at rest and will develop dizziness (usually lasting < 1 min) that is reliably triggered by a specific head movement or postural shift (i.e., standing or sitting up). Finally, patients with the spontaneous episodic vestibular syndrome (s-EVS) have multiple episodes of dizziness (usually lasting many minutes to many hours) that comes on without any clear identifiable trigger, even if there appear to be contextual predisposing factors (e.g., sleep deprivation, stress, or hormonal changes). Between episodes, they are completely asymptomatic. Table 1 shows the more common benign and serious causes for each of these three vestibular syndromes.

Accordingly, taking a history from patients with dizziness should be exactly like taking a history from patients with headache or chest pain and focuses on the duration, episodic or constant nature of the symptom, triggers if it is episodic, and other factors and associated symptoms and epidemiological context. The word used by the patient (e.g., vertigo vs. lightheadedness, or other terms) is unimportant, just as the patient descriptor of what kind of headache or chest pain (e.g., pressure vs. burning vs. stabbing) has very limited differential diagnostic utility. In one study, dizzy ED patients changed their type of dizziness ~50% of the time when asked repeated questions in a different sequence within 10 min.[9] In this same study, patients were far more consistent with their reporting of timing and triggers of symptoms. For simplicity, in this article we will use the term dizziness to mean any vestibular symptoms, including vertigo.

One of the most serious misdiagnoses that can occur in patients with dizziness is missed posterior circulation stroke. Because many symptoms of vertebrobasilar ischemia, especially in the cerebellum, are nonspecific (e.g., headache, dizziness, vomiting), misdiagnosis is not uncommon.[10] In one study of 1,666 ED patients presenting with acute dizziness, one-third of the patients who had strokes were missed in the ED.[11] Numerous studies using various methodologies have identified a presentation of dizziness and posterior circulation location as being risk factors for missed stroke diagnosis.[12–17] Misdiagnosis can result in poor patient outcomes.[18]

Misdiagnosis is partly due to physicians' misconceptions about factors that allow the diagnosis of a peripheral process.[3,19] Common examples include the false notion that symptoms that worsen with movement confirm a peripheral vestibular process and that a normal brain computed tomography (CT) scan is reassuring in excluding ischemic stroke.[3,19] A recent analysis of patients who presented to Canadian EDs with dizziness and were subsequently discharged showed that patients who had a (negative) CT scan had a twofold increased likelihood of stroke compared with those who were not scanned, suggesting that the emergency physicians (EPs) were correctly considering stroke but were falsely reassured by a negative CT result.[20] An additional finding was that CT scans were being overused and not in accordance with recommendations. The sensitivity of brain CT for posterior circulation acute ischemic stroke is low (7%–42%).[21–24]

Finally, although CT is an excellent test for an intracerebral hemorrhage, an intracerebral hemorrhage that mimics a benign dizziness presentation (no obvious, worrisome physical signs such as lethargy or hemiparesis) is rare.[25] The total annual cost for evaluating dizzy patients in United States (US) EDs now exceeds $4 billion.[26] Imaging accounts for 12% of the ED costs, 75% of which is attributable to CT scans. Most of these CT scans are not clinically useful and, as mentioned, can be falsely reassuring.[20,27–29]

Fortunately, growing evidence suggests that the physical examination can help physicians confidently make a specific peripheral vestibular diagnosis on the one hand, or suggest stroke on the other. Most of the data come from bedside examinations performed by specialists (stroke neurologists) or subspecialists (neuro-otologists).[30–32] However, there is nothing "magical" about these clinical tests and EPs can learn to perform and interpret them.[33]

Modern medical practice increasingly favors testing over physical examination. Magnetic resonance imaging (MRI), which is becoming increasingly available in real time, has been suggested as the gold standard for diagnosing acute ischemic stroke.[34] However, it is important to recognize that early MRI, even with diffusion-weighted imaging sequences (DWI), has important limitations in diagnosing acute ischemic stroke. Studies using delayed DWI-MRI or final clinical diagnosis as the gold standard have found frequent false negatives in the first 48 h after onset of symptoms. This is especially true for posterior fossa events.[21,31,32,35–38] It is also specifically true in dizzy patients.[31,32,38]

Taken together, these data suggest that physicians are using a diagnostic paradigm that is not consistent with current evidence, brain imaging, particularly CT, is overused, and misdiagnosis could be reduced. Fortunately, the physical examination is highly sensitive in these patients. This article will focus on how to use bedside physical examination to more accurately diagnose patients who present with acute dizziness, vertigo, or other similar vestibular symptoms (Figure 1).

Figure 1.

International expert consensus definitions related to dizziness and vertigo ( 39, 40).

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