Vestibular Disorders: Pearls and Pitfalls

Woo Young Choi, MD, PhD, FRCPC; Daniel R. Gold, DO


Semin Neurol. 2019;39(6):761-774. 

In This Article

Performing the Examination


A common pitfall to keep in mind is that the clinician may be falsely reassured by a normal general neurological examination of a patient with vestibular symptoms due to a small posterior fossa stroke.[27] Importantly, dizziness or vertigo is the most frequently presenting symptom in patients with posterior circulation ischemia,[28] and of those patients presenting with isolated vestibular symptoms due to stroke, approximately 80% will have a normal general neurologic examination.[29]

While the ocular motor examination is often abnormal in vestibular disorders,[29] it is frequently underused or misinterpreted by frontline physicians.[1,4] Many vestibular disorders have characteristic ocular motor findings that allow a specific diagnosis to be made with a high degree of certainty.[27] For example, posterior canal (PC) BPPV can be confidently diagnosed when symptoms are positionally-triggered, and the DH test elicits the characteristic transient upbeat-torsional nystagmus. Unfortunately, the DH test for PC BPPV is often misused and misinterpreted,[16,27] despite the fact that it is the gold standard for diagnosis. It is important to know that the DH test can also be misleading when performed in inappropriate circumstances, such as in a patient who has continuous symptoms or spontaneous nystagmus (i.e., both are features inconsistent with BPPV). For example, a patient with a VOR impairment (e.g., vestibular neuritis) or head motion intolerance with a normal VOR (e.g., vestibular migraine) will often experience more intense symptoms (and commonly more intense nystagmus as well) with the DH maneuver. Therefore, performing the DH in a patient with acute continuous vestibular symptoms will not help to establish the diagnosis (HINTS should be used here), but instead will aggravate the patient's symptoms and may lead to the examiner misinterpreting the DH as positive for BPPV.


Medical examination maneuvers (e.g., auscultation of the neck and heart, blood pressure, orthostatic measurements) should be performed when appropriate. Given the extensive ocular motor and vestibular pathways within the brainstem and cerebellum, a careful cranial nerve and eye movement examination is critical. The general neurologic examination can be normal in patients presenting with isolated dizziness or vertigo due to small brainstem or cerebellar strokes, but the ocular motor and vestibular examination will almost always provide the clues toward the correct diagnosis (Table 1).[27] Gait and stance are usually the most helpful components of the general neurologic examination in patients with isolated vestibular symptoms, specifically evaluating for truncal or gait ataxia. An otoscopic examination may provide clues regarding the etiology of dizziness, especially when a peripheral infectious etiology is suspected Box 2.