Evaluation of dizziness

Last reviewed: December 2018

Last updated: June 2018

Summary

Dizziness is a nonspecific term and may be used by patients to indicate true vertigo, lightheadedness, imbalance, or a form of syncope. The prevalence of dizziness in the general population ranges from 20% to 30%. [1] True vertigo is described as a rotary sensation of the patient or surroundings, and is often of vestibular origin.

Etiology

The etiology varies from vestibular, to neurologic, to cardiovascular pathology. The most common causes of vertigo are migraine-related vertigo, benign positional paroxysmal vertigo (BPPV), and Meniere disease. Cerebellar infarct or vestibular schwannoma (acoustic neuroma) may also cause dizziness.

History and clinical findings

It is important to take a detailed history of the patient's symptoms. True vertigo often indicates vestibular pathology (e.g., BPPV, labyrinthitis, or Meniere disease). Central pathology, such as a cerebellar ischemic stroke, needs to be ruled out. A description of the typical attacks including their nature, duration, and associated auditory symptoms (e.g., hearing loss; tinnitus and aural pressure) should be determined. Physical exam includes an ear and neurologic exam plus an exam of the vestibular system. Neurologic exam is important to rule out central pathology. The Dix-Hallpike test should be carried out if BPPV is suspected.

Investigations

The diagnosis of dizziness is usually made on the basis of the history and exam only. Investigations may not be necessary. MRI of the brain and internal auditory meatus should be done if there is concern that there may be central pathology. Vestibular function tests are indicated in some cases. Tests of cardiovascular function may be necessary if a cardiovascular cause is suspected.

Differentials

Common

Benign positional paroxysmal vertigo
Meniere disease
Vestibular neuritis
Labyrinthitis
Vestibular migraine
Syncope or presyncope
Orthostatic hypotension
Postural orthostatic tachycardia syndrome
Diabetes mellitus
Hypothyroidism
Rheumatoid arthritis
Alcohol
Drugs

Full details

Uncommon

Cholesteatoma
Superior semicircular canal dehiscence
Perilymphatic fistula
Mondini dysplasia
Posterior fossa tumor
Multiple sclerosis
Cerebellar stroke
Vertebrobasilar insufficiency
Chiari malformation type 1
Wallenberg syndrome
Trauma
Cervical artery dissection
Paraneoplastic cerebellar degeneration
Hereditary ataxia
Benign intracranial hypertension
Normal pressure hydrocephalus
Mal de debarquement syndrome
Psychophysiological dizziness
Psychogenic dizziness
SLE
Cogan syndrome
Wegener granulomatosis (granulomatosis with polyangiitis)
Behcet disease
Carbon monoxide poisoning
Postsurgery
Lyme disease
Syphilis
HIV
CMV
HSV-1

Full details

Contributors

Authors VIEW ALL 

Susan A. Douglas, MBBS (Hons) UWI, FRCSEd, FRCS (ORL-HNS)

Consultant Otolaryngologist and Otologist

Rotherham NHS Foundation Trust

Rotherham

Disclosures

SAD declares that she has no competing interests.

William Gibson, MD, FRCS, FRACS

Professor of ENT

Sydney Cochlear Implant Centre

Sydney

Australia

Disclosures

WG is a co-author of one reference cited in this monograph.

Peer reviewers VIEW ALL 

Joel Goebel, MD, FACS

Professor and Vice Chairman

Residency Program Director

Dizziness and Balance Center Director

Otolaryngology-Head and Neck Surgery

Washington University School of Medicine

St. Louis

Disclosures

JG is an author of a number of references cited in this monograph.

Iain Swan, MD, FRCS

Senior Lecturer in Otolaryngology

Honorary Consultant Otolaryngologist

Glasgow Royal Infirmary

Glasgow

Disclosures

IS declares that he has no competing interests.

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Evaluation of dizziness

Summary

Etiology

History and clinical findings

Investigations

Differentials

Common

Uncommon

Contributors

Authors VIEW ALL 

Susan A. Douglas, MBBS (Hons) UWI, FRCSEd, FRCS (ORL-HNS)

Disclosures

William Gibson, MD, FRCS, FRACS

Disclosures

Peer reviewers VIEW ALL 

Joel Goebel, MD, FACS

Disclosures

Iain Swan, MD, FRCS

Disclosures

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