Examination of the patient with dizziness

• The examination of the 'dizzy' patient is directed by the history. Components include: (1)
  • neurological examination
  • head and neck examination
  • examination of the cardiovascular system
• neurological examination (1)
  • cranial nerves should be examined for :
    • signs of palsies and sensorineural hearing loss
      • this includes particularly
        • fundoscopy for papilloedema or optic atrophy (II)
        • eye movements (III, IV, and VI)
        • corneal reflex (V)
        • facial movement (VII)
        • tuning folk tests for hearing loss(VIII)
      • special attention is paid to those that pass through the cerebellopontine angle - the fifth to the seventh.
    • nystagmus
      • common in acute vertigo (2)
        • vertical nystagmus (1)
          • is commonly seen in vestibular nuclear or cerebellar vermis lesions
        • horizontal nystagmus
          • is present in acute vestibular neuronitis
  • cerebellar function is tested via the finger-nose test
  • Romberg's sign (1)
    • not very useful in the diagnosis of vertigo
  • Dix-Hallpike maneuver (1)
    • the most helpful test to perform for vertigo
  • Unterberger's stepping test
• head and neck examination (1)
  • Hennebert's sign
    • pushing on the tragus and external auditory meatus of the affected side causes vertigo or nystagmus
    • indicates the presence of a perilymphatic fistula
  • peripheral auditory system
    • pneumatic otoscopy
      • examine tympanic membranes for
        • vesicles (Ramsay Hunt syndrome)
        • cholesteatoma
    • tuning fork tests (also mentioned above)
  • assess neck movements - an arthritic cervical spine may be the source of abnormal proprioceptive signals
  • auscultation of the neck for bruits
• cardiovascular examination
  • the following orthostatic changes systolic in blood pressure and pulse when the patient is made to stand suggests autonomic dysfunction
    • systolic blood pressure-drop of 20 mm Hg or more
    • pulse - rise of 10 beats per minute
  • arrhythmias
    • check for postural hypotension

Reference:

1. Ronald H. Labuguen, Initial Evaluation of Vertigo, American Family Physician ,Vol. 73/No. 2 (January 15, 2006)
2. J Kanagalingam ,et al, Vertigo, BMJ, Mar 2005; 330:523