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

Final Pearls

As patients with vestibular disorders report symptoms that are often vague and imprecise, a systematic approach to dizziness is essential. Rather than emphasizing symptom quality, it is more helpful to use the Triage-TiTrATE-Test method in order to categorize vestibular disorders based on timing, triggers, and duration, followed by focused oculomotor and vestibular examinations. In the acute vestibular syndrome, clinicians should not overemphasize neuroimaging (head CT is very low yield, and MRI may miss up to 20% of small posterior fossa strokes in the first 24–48 hours) or general neurologic examination (normal 80% of the time in patients with isolated dizziness or vertigo due to stroke). Instead, the clinician should focus on the HINTS "Plus" examination, adding head shaking, evaluation of saccades and smooth pursuit, and positional testing (mainly looking for central patterns) as needed. In the spontaneous episodic vestibular syndrome (occurring in isolation or with aural symptoms), clinicians should always consider TIA in the differential, especially in patients with vascular risk factors or head or neck pain suggesting dissection. Vestibular migraine is a much more common disorder compared with Meniere's disease, but when low-mid frequency sensorineural hearing loss is seen in a patient with recurrent vertigo, Meniere's is more likely. In the chronic vestibular syndrome, it is essential to perform a general neurologic examination, including gait assessment, as well as ocular motor and vestibular examinations. Using the systematic approach described in this review, the vast majority of vestibular diagnoses can be readily made at the bedside.