1. Not all dizziness is vertigo.
Dizziness is a common, non-specific symptom. It is an all-encompassing term within which patients may describe vertigo, presyncope, disequilibrium or lightheadedness.
Pathologies that may cause dizziness include disorders of the vestibular, cardiovascular and central nervous systems. Anxiety, depression or panic attacks may also present with dizziness.
It is really important to obtain a good history – since most patients presenting with dizziness can be diagnosed by history alone.
2. Be aware of the symptoms of peripheral vestibular dysfunction
Most lesions causing vertigo are because of peripheral vestibular dysfunction.
These tend to cause severe, prostrating, rotatory vertigo associated with nausea and vomiting.
Patients usually clearly describe the onset, duration and precipitating factors. Associated symptoms suggesting an inner ear cause include hearing loss, tinnitus and aural fullness.
3. Exclude CNS disorders if there is loss of consciousness.
CNS disorders causing vertigo are considerably less common than peripheral vestibular dysfunction, and may be associated with evidence of focal neurological dysfunction such as diplopia, dysarthria, dysphagia, paresis, paraesthesia and incontinence. If loss of consciousness occurs, CNS or cardiac abnormality must be excluded.
4. Examine the ears and eyes.
Examine the ears to exclude active ear disease. Tuning fork tests may reveal a conductive or sensorineural hearing loss. Abnormal eye movements may suggest either peripheral or central vestibular dysfunction. Also, a lying and standing blood pressure may reveal postural hypotension.
Perform a Hallpike manoeuvre as benign positional vertigo is the most common inner ear cause of vertigo and is treatable.
A description of how to perform the Hallpike manoeuvre is available in Case-based learning: vertigo and tuning fork tests are covered in Key questions on hearing problems.
5. Look out for cochlear symptoms or neurological dysfunction.
Any cochlear symptoms such as a unilateral sensorineural hearing loss or persistent tinnitus, or suggestion of neurological dysfunction, require further assessment by a specialist and probably an MRI scan to exclude intracranial pathology.
6. Try asking patients to hyperventilate.
Often GPs are presented with a patient suffering with a degree of anxiety that may either cause, or heighten, their symptoms.
In the absence of any abnormal signs on examination, asking the patient to hyperventilate for one minute may reproduce their symptoms and allow a diagnosis of psychogenic dizziness to be made.
7. Stop vestibular suppressants as soon as possible.
Vestibular suppressants should be used to treat the acute symptoms of vertigo, especially when they last for hours or days, but should be discontinued as soon as the patient's symptoms allow – tapering them off over about a week.
Avoid drugs such as prochlorperazine long term – they can cause drowsiness, which may exacerbate the symptoms of dizziness or cause poor central compensation from a peripheral vestibular insult. They can also increase the risk of Parkinson's disease.
8. Consider referring for vestibular rehabilitation.
Damage to the vestibular system causing vertigo may leave the patient with persistent unsteadiness. Central compensation usually occurs over the following few weeks, but this is less likely if patients lose confidence and limit their activities.
Many audiology departments offer vestibular rehabilitation, repeating different exercises – a sort of physiotherapy of the balance system – which can be very effective.
9. Don't forget to reassure patients.
It is important to remember that the symptoms of vertigo can be frightening. In most patients, symptoms are self-limiting and not life-threatening – and most will recover with no major problems.
But all patients benefit from the knowledge that they will recover and from, if possible, information regarding their prognosis.
10. Seek advice for patients with intractable symptoms.
In the last few years, there have been new treatments for diseases such as Meniere's disease, including intratympanic gentamycin and intratympanic steroids, along with the introduction of the Meniette device – which is used by the patient to generate a low-pressure pulse through a grommet to the middle ear space. For patients who have intractable symptoms it is always worth seeking further advice.
Mr Andy Bath is an ENT consultant at Norfolk and Norwich University Hospital
