Diagnosis of dizziness

The diagnostic algorithm for dizziness can be represented as follows.

• Establishment of the presence of dizziness.
• Determination of the type of dizziness.
• Clarification of the causes of dizziness.
• Identification of neurologic or otiatric symptoms (examination of an ENT doctor).
• Instrumental studies depending on the detected symptoms (neuroimaging, hearing research, evoked potentials, etc.).

[1], [2], [3], [4]

Anamnesis and physical examination

Examination of a patient with complaints of dizziness implies the establishment of the very fact of dizziness and clarification of its topical and nosological affiliation. Often patients put in the notion of vertigo the most diverse meaning, including, for example, impaired vision, nausea, headache, etc. In this situation, the doctor's task is to conduct differential diagnosis between dizziness and complaints of a different nature. During the questioning, one should not push the subject to the naming of a specific term, it is much more expedient to obtain from him the most detailed description of complaints. Of great importance is the neurological examination, in particular, the identification and determination of the nature of the nystagmus (its directivity, symmetry, connection with the position of the head, etc.), the state of the cranial nerves and the precision of the coordination tests, and the detection of focal neurological deficit. Many patients require an examination of an otiatrist or an otoneurologist using instrumental methods for diagnosing the state of the vestibular apparatus, hearing, and vision. Even a full-fledged examination in a number of cases does not allow you to establish a diagnosis, which requires a dynamic observation of the patient. Especially difficult is the diagnosis of combined forms of dizziness. Significant diagnostic value is the rate of development of the disease, the events preceding it and provoking factors: the acute onset is more typical for peripheral lesions, while the gradual development is for the central one. Peripheral lesions are typical of hearing impairment (ear noise, obstruction, deafness), while the symptoms of lesions of other parts of the brain (large hemispheres, trunk) testify to the central lesion. Expressed vestibular disorders with severe nausea, repeated vomiting are more often observed in the vestibular pathological process. The occurrence or increase of dizziness when head position changes in overwhelming majority of cases testify to peripheral lesion and relatively benign character of the process. Help in establishing the diagnosis can provide information about the transferred inflammatory, autoimmune diseases, intoxications (including medicinal), head injuries.

With a neurologic examination, special attention should be paid to nystagmus. First, check the presence of nystagmus when looking in front of you (spontaneous nystagmus), then - when looking to the sides, with eyeballs at 30 ° from the middle position (called nystagmus). The occurrence of induced nystagmus by intense shaking of the head (about 20 s) indicates a peripheral lesion.

Of exceptional importance in the diagnosis of PDPH is the Holpike test. A patient with open eyes sits on the couch, turning his head 45 ° to the right. Slightly supported by the shoulders, the patient quickly descends to the back so that his head hangs from the edge of the couch by 30 °. Then the study is repeated with the head turning in the opposite direction. The sample is considered positive if, after a few seconds of being in the final position, systemic dizziness occurs and a horizontal nystagmus appears.

The otiatric examination includes examination of the external auditory canal (identification of sulfur plugs, traces of recent trauma, acute or chronic infections), tympanic membrane, bone and air conduction studies (Weber and Rinne tests).

[5], [6], [7], [8], [9], [10]

Laboratory and instrumental diagnostics of dizziness

Of exceptional importance are CT or MRI of the head to exclude tumors, demyelinating process, other structural changes of acquired and innate character. Radiography of the skull is less informative, although it reveals fractures of the bones of the skull, expansion of the internal auditory canal with neurinoma of the pre-collar nerve.

If a vascular etiology of the disease is suspected, ultrasound dopplerography 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 revealed changes in blood vessels are not always the cause of the existing vestibular disorders. In an even greater degree, this concerns changes in the cervical spine: revealed osteochondrosis, osteoarthrosis, spondylosis rarely have anything to do with dizziness.

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

With accompanying hearing impairments, it is advisable to perform tonal audiometry, as well as recording of auditory evoked potentials. The registration of an audiogram after taking glycerol (a test with dehydration, which allows to reduce the severity of endolymphatic gypsum) allows to detect an improvement in low frequency perception and improvement of speech intelligibility, which is indicative of Meniere's disease. An objective method of diagnosing Meniere's disease is also electrochlear.

Do not forget about the EEG to exclude paroxysmal or epileptic activity in the temporal leads or signs of brain stem dysfunction.

Diagnosis of dizziness complaints

General blood analysis; determination of fasting blood sugar; urea nitrogen in the blood; electrolytes (Na, K, O) and CO2; investigation of cerebrospinal fluid; radiography of the chest, skull and internal auditory meatus; roentgenography of the cervical spine; ultrasound dopplerography of the main arteries of the head; compression-functional tests, duplex scanning, transcranial dopplerography with pharmacological tests, CT or MRI; ECG; otoneurologic examination with audiography and vestibular passport research; ophthalmodinamometry; carotid sinus massage; cardiovascular tests. If necessary, the therapist may be recommended and other studies.

[11], [12], [13], [14]

Diagnostic criteria for phobic postural dizziness

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

1. Vertigo and complaints take place while standing and walking, despite the normal performance of such stability tests, like Romberg's test, tandem walking, standing on one leg and routine post-study.
2. Postural dizziness is described by the patient as a fluctuating instability, often in the form of attacks (seconds or minutes), or sensation of an illusory breach of body stability lasting a fraction of a second.
3. Dizziness attacks appear spontaneously, but are often associated with special perceptual stimuli (bridging, stairs, empty space) or a social situation (department store, restaurant, concert hall, meeting, etc.), from which the patient is difficult to refuse and perceived as provoking factors.
4. Anxiety and vegetative symptoms accompany dizziness, although dizziness can also be without anxiety.
5. Typical obsessive-compulsive personality type, affective lability and mild reactive depression (in response to dizziness).
6. The onset of the disease often follows a period of stress experienced or after a disease with vestibular disorders.

Similar dizziness may occur in the picture of agoraphobic disorders and (more rarely) panic attacks, in the picture of functional-neurological (demonstrative) disorders or as part of complex somatoform disorders along with others (gastrointestinal, painful, respiratory, sexual and other) somatic disorders that can not be explained by any real disease. Most often in such cases, there is a "pseudo-ataxia" in the context of anxious-phobic and (or) conversion disorders. This type of dizziness is difficult for objectification and is diagnosed on the basis of positive diagnosis of mental (neurotic, psychopathic) disorders and exclusion of the organic nature of the disease.

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

In the implementation of differential diagnosis of vertigo, the most important is the analysis of patient complaints and concomitant somatic and neurological manifestations.

[15], [16], [17], [18], [19],