Clinical evaluation

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Clinical evaluation Approach Dr
Sohrab Rabiei otolaryngologist
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Clinical evaluation Approach

• History
• Physical examination
• Testing - laboratory office
• Radiologic
• Differential diagnosis
• Diagnostic criteria

• Acute care/hospitalization
• Medical therapy
• Invasive approach
• Complication
• Especial circumstances
• Consult and refer
• Prognosis
• Pt education
• Follow up

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History

• Attempt to define the true qualitative nature of
  the symptom complex by asking for an exact
  description of what the patient means by
  "dizziness," without biasing the outcome by
  providing descriptive words
• 2) Ask about the temporal course of the symptoms.

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3)Ask about associated symptoms, such as
tinnitus, hearing loss, double vision, numbness,
nausea, or vomiting. 4)Review the patient's
general medical history and records for evidence
of hypertension, diabetes mellitus, heart
disease, endocrine disease, or psychiatric
illness.
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5) Review the patient's history of drug use
(prescription, OTC, herbal) and any adverse
effects . 6) Ask about precipitating factors such
as trauma, undue stress, or apparent viral
infection.
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A minimum vertigo history should address the
following

• the duration of the individual attack, that is,
  hours versus days
• frequency, that is, daily versus monthly
• the effect of head movements, that is, worse,
  better, or no effect
• inducing position or posture, for example,
  rolling onto the right side in bed
• associated aural symptoms such as hearing loss
  and tinnitus
• concomitant or prior ear disease and/or ear
  surgery

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Vertigo duration

• 1)Vertigo lasting minutes to hours
• a. Idiopathic endolymphatic hydrops
  (meniere's disease)b. Secondary endolymphatic
  hydrops(1) Otic syphilis(2) Delayed
  endolymphatic hydrops(3) Cogan's disease(4)
  Recurrent vestibulopathy

3)Vertigo lasting days vestibular
neuronitis
4)Vertigo of variable duration a. Inner ear
fistula b. Inner ear trauma(1) Nonpenetrating
trauma(2) Penetrating trauma(3) Barotrauma
2)Vertigo lasting seconds benign paroxysmal
positional vertigo
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Physical Examination
6) Examine the patient for middle-ear disease or
hearing loss using an otoscope and the Rinne
test. more

• 1) Perform a general physical examination,
  focusing on orthostatic measurements and other
  cardiovascular signs.

2) Evaluate the patient's motor coordination and
sensory function for the presence of unsteady
gait, past-pointing, or ataxia.
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4) Examine the eyes (preferably in a dim light)
for nystagmus.
3) Perform the Romberg test (using necessary
precautions to protect the patient from injury)
to assess proprioceptive function.
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5) As a means to diagnose BPPV in patients
presenting with vertigo, perform the Dix-Hallpike
provocative maneuver .
6) Examine the patient for middle-ear disease or
hearing loss using an otoscope and the Rinne
test.
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Bedside examination

• General ENT examination
• PTA and audiologic evaluation
• Cranial nerve examination

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• Spontaneous Nystagmus
• Head-shaking nystagmus
• Positional nystagmus
• Dynamic visual acuity
• Valsalva induced nystagmus
• Hyperventilation
• Nystagmus due to sound or pressure
• Tullio (vertigo induced by sound )
• Hennebergs ( vertigo induced by pressure )

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Testing office and laboratory

• 1) Target laboratory tests to suspected
  conditions .

2) Consider requesting electronystagmography to
evaluate vestibular function in patients with
questionable/complex disorders.
3) Consider computerized rotational testing to
quantitate bilateral reduced vestibular function,
such as occurs with drug ototoxicty.
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4) Consider requesting posturography, if
available, to quantify the Romberg test in
patients with equivocal balance disorders.
5) Perform an audiogram in patients with possible
hearing loss.
6) Consider brainstem auditory evoked-response
testing in patients with unexplained hearing
loss.
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Basic screening

• 1-Blood glucose level Possible diabetes
• 2- Complete blood count Possible infection or
  anemia
• 3- Electrolyte levels Possible imbalance
  hyponatremia, hypocalcemia
• 4-Thyroid-function test (e.g., serum TSH, T4)
  Possible hypothyroidism
• 5- Lipid levels Possible hyperlipidemia

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Radiologic

• Obtain a CT head scan in patients with suspected
  central nervous system pathology.
• 2) Obtain a head MRI for patients with persistent
  symptoms that suggest a disorder of the central
  nervous system.

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Differential Diagnosis

• First, based on the history and physical
  examination findings, determine whether the
  patient's dizziness is most likely to be caused
  by a peripheral, central, or systemic disorder

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• Second, compare the clinical findings with the
  characteristic manifestations of each of the
  diseases within the most likely category (i.e.,
  peripheral, central, or systemic).

• Third, if the diagnosis is still not obvious,
  focus further investigations on the limited
  number of remaining diagnostic possibilities.

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Diagnostic Criteria

• Based on the clinical history, physical
  examination findings (especially nystagmus), and
  laboratory test results (if needed), classify the
  cause of dizziness into one of three categories
  (peripheral, central, or systemic) . Then, if
  possible, make a specific diagnosis based on the
  same information.

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Acute Care/Hospitalization

• Immediately hospitalize patients with new onset
  of vertigo accompanied by neurologic signs and
  symptoms such as double vision, limb numbness, or
  slurred speech.

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Medical Therapy

• Treat the underlying disorder in patients with a
  definitive diagnosis.

• Consider the use of vestibular suppressants for
  symptomatic treatment of dizziness of probable
  peripheral origin

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• Prescribe exercise therapy, such as an Epley-type
  maneuver, as therapy in all patients with BPPV.

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Invasive Approaches

• Consider surgery as a last resort for patients
  with clearly defined severe attacks of peripheral
  vestibulopathy that are refractory to medical
  therapy.

• Direct surgical treatment of central causes of
  dizziness to the underlying diagnosis.

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Special Circumstances

• Be aware of syncope, presyncope, and severe
  lightheadedness as common accompaniments of
  pregnancy.

• Be alert for faintness or lightheadedness in
  patients with medical conditions that affect
  blood pressure.

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When to Consult or Refer

• Refer to a otolaryngologist Patients with BPPV

• Refer to a otolaryngologist Patients with
  progressive, disabling Meniere's disease

• Consider referring patients with cardiovascular
  findings to a cardiologist.

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• Refer to a neurologist patients with central
  nervous system signs or symptoms
• Patients with central vestibular, cerebellar, or
  focal neurologic findings, who should undergo
  further neurologic testing
• Atypical nystagmus or central nystagmus

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• If the patient has psychiatric problems (e.g.,
  panic disorder or depression) that do not
  sufficiently respond to simple reassurance and
  standard drug management, consider referral to a
  psychiatrist.

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Patient Education /General Advice

• If appropriate, instruct patients with BPPV on
  how to perform exercise therapy at home.

• Reassure patients with peripheral vestibulopathy
  that most symptoms improve with time.

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• To help relieve the side effects of anxiety and
  depression, extra understanding and patience
  should be used with patients with chronic
  dizziness who have seen many physicians.

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Thanks for your attention

• Please send your comments to
• SRABIEI_at_KUMS.AC.IR