AAO-HNSF Primary Care Otolaryngology Handbook

CHAPTER 6

Dizziness

Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (BPPV)

People often come to the otolaryngologist with a complaint of “dizzi- ness,” a general term that can refer to symptoms such as vertigo, disequilibrium, syncope, lightheadedness, or ataxia. The etiologies of dizziness can be classified into several categories: vestibular, cardiovas- cular, neurologic, psychiatric, and metabolic. As otolaryngologists, we focus on the treatment of vestibular disorders, which usually manifest as vertigo—an illusion of motion. Common peripheral vestibular disor- ders include benign paroxysmal positional vertigo (BPPV), vestibular neuronitis, labyrinthitis, Ménière’s disease, perilymphatic fistula, supe- rior semicircular canal dehiscence, bilateral vestibular hypofunction, and ototoxicity from certain medications. When central vestibular disorders are considered, the differential diagnosis becomes even broader. If your patient does not complain of the true illusion of motion, redirect your questioning to the evaluation of the other disease catego- ries. You may want to consider imaging studies of the brain to assess for a neoplasm, demyelinating disease, or a vascular abnormality, or consider referral to a neurologist or cardiologist. Patient Evaluation Office evaluation of dizzy patients should include a complete history and head and neck physical examination, as detailed in Chapter 1. In speaking with the patient, additional areas on which to focus include obtaining a description of the nature of the “dizziness,” when and how it started, anything that makes it better or worse, its severity, if it is continuous or episodic, and how long it lasts. The exam should include a detailed ear exam, along with tests of the vestibular and balance systems. Briefly, these include the Dix-Hallpike and supine roll tests, head impulse and head shake maneuvers, assessments of coordination and gait (rapid alternating movements, finger-nose-finger test, Romberg test, normal and tandem gait), and evaluation of eye movements (nystagmus, move- ments evoked by sound or changes in middle ear pressure).

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Primary Care Otolaryngology