The diagnostic algorithm for dizziness can be presented as follows.

  • Determining the presence of dizziness
  • Determining the type of dizziness
  • Finding out the causes of dizziness
  • Detection of neurological or otiatric symptoms (examination by an ENT doctor)
  • Instrumental studies depending on the identified symptoms (neuroimaging, hearing testing, evoked potentials, etc.)

History and examination for diagnosing dizziness

Examination of a patient with complaints of dizziness involves establishing the very fact of dizziness and clarifying its topical and nosological affiliation. Patients often give the concept of dizziness a wide variety of meanings, including, for example, blurred vision, a feeling of nausea, headache, etc.

In this situation, the doctor’s task is to carry out a differential diagnosis between dizziness and complaints of a different nature. During questioning, you should not push the subject to name a specific term; it is much more advisable to obtain from him the most detailed description of the complaints.

A neurological examination is of great importance, in particular, identifying and determining the nature of nystagmus (its direction, symmetry, connection with the position of the head, etc.), the state of the cranial nerves and the accuracy of the coordination tests, as well as identifying focal neurological deficits.

Many patients require examination by an otologist or otoneurologist using instrumental methods for diagnosing the condition of the vestibular apparatus, hearing, and vision.

Even a full examination in some cases does not allow establishing a diagnosis, which requires dynamic monitoring of the patient.

Diagnosis of combined forms of dizziness is especially difficult. The rate of development of the disease, the events preceding it and provoking factors are of significant diagnostic importance: an acute onset is more typical for peripheral lesions, while gradual development is more typical for central ones. For peripheral lesions, hearing impairment (tinnitus, congestion, hearing loss) is typical, while symptoms of lesions in other parts of the brain (cerebral hemispheres, brainstem) indicate a central lesion.

Severe vestibular disorders with severe nausea and repeated vomiting are more often observed with a vestibular pathological process.

The occurrence or intensification of dizziness when changing the position of the head in the vast majority of cases indicates a peripheral lesion and the relatively benign nature of the process. Help in establishing a diagnosis can be provided by information about past inflammatory and autoimmune diseases, intoxications (including drugs), and head injuries.

During neurological examination, special attention should be paid to nystagmus. First, the presence of nystagmus is checked when looking in front of you (spontaneous nystagmus), then when looking to the sides, when the eyeballs are abducted 30° from the average position (gaze-induced nystagmus). The occurrence of nystagmus induced by intense shaking of the head (about 20 s) indicates a peripheral lesion.

The Hallpike test is extremely important in the diagnosis of BPPV. The patient sits on the couch with his eyes open, turning his head 45° to the right. Lightly supported by the shoulders, the patient quickly lowers himself onto his back so that his head hangs 30° from the edge of the couch. Then the study is repeated with the head turned in the other direction. The test is considered positive if, after a few seconds of being in the final position, systemic dizziness occurs and horizontal nystagmus appears.

Otiatric examination includes examination of the external auditory canal (identification of cerumen plugs, traces of recent trauma, acute or chronic infections), eardrum, study of bone and air conduction (Weber and Rinne tests).

Laboratory and instrumental diagnostics of dizziness

CT or MRI of the head is of exceptional importance to exclude neoplasms, demyelinating process, and other structural changes of an acquired or congenital nature. X-ray of the skull is less informative, although it can reveal fractures of the skull bones, expansion of the internal auditory canal with neuroma of the vestibulocochlear nerve.

If a vascular etiology of the disease is suspected, Doppler ultrasound of the main arteries of the head and intracranial vessels (or MR angiography) should be performed. However, it should be borne in mind that the detected vascular changes are not always the cause of existing vestibular disorders. This applies to an even greater extent to changes in the cervical spine: identified osteochondrosis, osteoarthrosis, and spondylosis extremely rarely have anything to do with the occurrence of dizziness.

If infectious diseases are suspected, it is advisable to study the cellular composition of the blood and determine antibodies to the suspected pathogens.

In case of concomitant hearing impairment, it is advisable to conduct pure-tone audiometry, as well as registration of auditory evoked potentials. Recording an audiogram after taking glycerol (a test with dehydration to reduce the severity of endolymphatic hydrops) reveals an improvement in the perception of low frequencies and improved speech intelligibility, which indicates Meniere’s disease. Electrocochleography is also an objective method for diagnosing Meniere’s disease.

We should not forget to conduct an EEG to exclude paroxysmal or epileptic activity in the temporal leads or signs of brain stem dysfunction.

Diagnostic tests for complaints of dizziness

  • General blood analysis;
  • determination of fasting blood sugar;
  • blood urea nitrogen;
  • electrolytes (Na, K, O) and CO2;
  • cerebrospinal fluid examination;
  • X-ray of the chest, skull and internal auditory canal;
  • X-ray of the cervical spine;
  • Doppler ultrasound of the main arteries of the head;
  • compression-functional tests, duplex scanning, transcranial Doppler ultrasound with pharmacological tests, CT or MRI;
  • ECG;
  • otoneurological examination with audiography and vestibular passport examination;
  • ophthalmodynamometry;
  • carotid sinus massage;
  • cardiovascular tests.

If necessary, the therapist may recommend other studies.

Diagnostic criteria for phobic postural vertigo

This diagnosis is based mainly on the following 6 characteristic manifestations.

  • Dizziness and complaints occur while standing and while walking, despite normal performance of stability tests such as the Romberg test, tandem walking, one-legged standing and routine posturography.
  • Postural dizziness is described by the patient as fluctuating instability, often in the form of attacks (seconds or minutes), or a sensation of illusory instability of the body lasting a fraction of a second.
  • Attacks of dizziness appear spontaneously, but are often associated with special perceptual stimuli (overcoming a bridge, stairs, empty space) or a social situation (department store, restaurant, concert hall, meeting, etc.), which are difficult for the patient to refuse and which are perceived by him as provoking factors.
  • Anxiety and autonomic symptoms accompany dizziness, although dizziness can occur without anxiety.
  • An obsessive-compulsive personality type, affective lability and mild reactive depression (in response to dizziness) are typical.
  • The onset of the disease often follows a period of stress or after an illness with vestibular disorders.

Similar dizziness may occur in the picture of agoraphobic disorders and (less often) panic attacks, in the picture of functional neurological (demonstrative) disorders, or be part of complex somatoform disorders along with others (gastrointestinal, pain, respiratory, sexual and others) somatic disorders that cannot be explained by any real disease. Most often in such cases, “pseudoataxia” occurs in the context of anxiety-phobic and (or) conversion disorders. This type of dizziness is difficult to objectify and is diagnosed on the basis of a positive diagnosis of mental (neurotic, psychopathic) disorders and the exclusion of the organic nature of the disease.

At the same time, the presence of affective accompaniment of dizziness in the form of feelings of anxiety, fear or even horror does not exclude the organic nature of dizziness, since any dizziness: both systemic (especially paroxysmal) and non-systemic, are themselves extremely stressful, which must always be taken into account in the process of their treatment .

When making a differential diagnosis of dizziness, the most important thing is to analyze the patient’s complaints and accompanying somatic and neurological manifestations.

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