Evaluation Of Vertigo Research Articles

Development of a diagnostic protocol for dizziness in elderly patients in general practice: a Delphi procedure

BackgroundDizziness in general practice is very common, especially in elderly patients. The empirical evidence for diagnostic tests in the evaluation of dizziness is scarce. Aim of our study was to determine which set of diagnostic tests should be part of a diagnostic protocol for evaluating dizziness in elderly patients in general practice.MethodsWe conducted a Delphi procedure with a panel of 16 national and international experts of all relevant medical specialities in the field of dizziness. A selection of 36 diagnostic tests, based on a systematic review and practice guidelines, was presented to the panel. Each test was described extensively, and data on test characteristics and methodological quality (assessed with the Quality Assessment of Diagnostic Accuracy Studies, QUADAS) were presented. The threshold for in- or exclusion of a diagnostic test was set at an agreement of 70%.ResultsDuring three rounds 21 diagnostic tests were selected, concerning patient history (4 items), physical examination (11 items), and additional tests (6 items). Five tests were excluded, although they are recommended by existing practice guidelines on dizziness. Two tests were included, although several practice guidelines question their diagnostic value. Two more tests were included that have never been recommended by practice guidelines on dizziness.ConclusionIn this study we successfully combined empirical evidence with expert opinion for the development of a set of diagnostic tests for evaluating dizziness in elderly patients. This comprehensive set of tests will be evaluated in a cross-sectional diagnostic study.

What Do We Really Know About Neurological Misdiagnosis in the Emergency Department?

To the Editor: Caplan's recent editorial1Caplan LR Dizziness: How do patients describe dizziness and how do emergency physicians use these descriptions for diagnosis?.Mayo Clinic Proc. 2007; 82: 1313-1315Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar on the evaluation of dizziness in the emergency department (ED) highlights many shortcomings of the emergency physician in evaluating neurological symptoms. We agree that history taking and physical examinations performed by emergency physicians are sometimes incomplete and that more extensive training in neurology would be ideal. However, the assertion that “the training of ED physicians in neurology is grossly inadequate” overstates the anecdotal, survey,2Stanton VA Hsieh Y-H Camargo Jr, CA et al.Overreliance on symptom quality in diagnosing dizziness: results of a multicenter quantitative survey of emergency physicians.Mayo Clin Proc. 2007; 82: 1319-1328Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar and retrospective case review3Savitz SI Caplan LR Edlow JA Pitfalls in the diagnosis of cerebellar infarction.Acad Emerg Med. 2007; 14: 63-68Crossref PubMed Google Scholar, 4Weintraub MI Thrombolysis (tissue plasminogen activator) in stroke: a medicolegal quagmire.Stroke. 2006 Jul; 37 (Epub 2006 May 25.): 1917-1922Crossref PubMed Scopus (94) Google Scholar evidence on which Caplan's editorial is based. Furthermore, many attributes of emergency physicians are essential for quality neurological care in the emergency setting. Generally speaking, the strengths of neurologists are to exhaustively evaluate a single patient, develop and enact a diagnostic plan, and then develop and enact a therapeutic plan. This approach requires considerable, albeit necessary, time; at our institution, consultation with a neurologist routinely prolongs a patient's stay in the ED by 4 to 6 hours. The strengths of emergency physicians are to rapidly assess, stabilize, diagnose, treat, and direct disposition for numerous, diverse patients simultaneously. This approach might minimize subtle findings and lead to misdiagnosis. Combining the strengths of the neurologist and emergency physician is necessary for optimal treatment of neurological emergencies. We believe emergency medicine programs would welcome the expertise of neurologists in training emergency physicians. If neurologists desire to work in the ED, as proposed by Caplan, they will need more training in emergency medicine to effectively perform in this setting. Efficiency in evaluating dozens of patients preceding a patient with an ischemic stroke can be as important to that stroke patient's safety as the care he or she directly receives. The window for thrombolysis can quickly be lost in the waiting room if the ED is not managed efficiently. We hold great respect for our neurologist colleagues and hope the fields of neurology and emergency medicine will continue to collaborate to advance the care of patients with neurological emergencies. What Do We Really Know About Neurological Misdiagnosis in the Emergency Department?Mayo Clinic ProceedingsVol. 83Issue 2PreviewTo the Editor: A recent editorial1 that accompanied 2 articles about the diagnosis of dizziness in patients in the emergency department (ED)2,3 presented anecdotal evidence and opinions that might be misconstrued by readers as firm scientific evidence. Full-Text PDF What Do We Really Know About Neurological Misdiagnosis in the Emergency Department?Mayo Clinic ProceedingsVol. 83Issue 2PreviewTo the Editor: As representatives for osteopathic emergency physicians in the United States, we respond to the recent editorial by Dr Caplan.1 His comment that patients with acute neurological problems are “at risk when they go to an ED [emergency department] if they are not seen by a neurologist” is a viewpoint backed by faulty or misinterpreted data. Full-Text PDF

Vertigo in childhood: A clinical experience

Vertigo in childhood is a complaint consisting of a wide spectrum of diagnoses. The aim of this study was to evaluate pediatric patients with vertigo with normal eardrum and middle ear findings and discuss the differential diagnoses. Patient records of 50 children under 18 years of age with vertigo as the chief complaint, examined at the Baskent University, Research and Application Centers at Konya and Adana otorhinolaryngology clinics between May 2003 and October 2005 were retrospectively reviewed. The questionnaires, laboratory tests including blood samples, audiological and vestibular tests, and final diagnoses were analyzed. Patients with perforated eardrums, otitis media with effusion, and acute upper respiratory tract infections were not included in the study. The study group consisted of 50 patients (33 females, 66%; 17 males, 34%), between 4 and 17 years of age (mean age, 11.5+/-3.9 years). Severe sensorineural hearing loss was present in one patient unilaterally (2%) and one patient bilaterally (2%). Bilateral low-frequency sensorineural hearing loss was present in one patient (2%). Electronystagmography revealed central vestibular abnormalities in three patients (6%). Canal paresis was established in six patients (12%). The Dix-Hallpike test was positive in six patients (12%). The most frequent cause of vertigo was migraine, occurring in 34% of patients (n=17). Other less-frequent etiologies of vertigo were benign paroxysmal vertigo (n=6; 12%), benign paroxysmal positional vertigo (n=6; 12%), psychogenic vertigo (n=5; 10%), epilepsy (n=3; 6%), metabolic disorders (n=3; 6%), vestibular neuritis (n=2; 4%), Meniere's disease (n=1; 2%), perilymphatic fistula (n=1; 2%), amblyopia (n=1; 2%), and unclassifiable (n=5; 10%). Migraine was found to be the most frequent presenting diagnosis in childhood vertigo, although several peripheral vestibular disorders also were diagnosed. Evaluation of vertigo in childhood should begin with a thorough neuro-otologic evaluation and include other relevant multidisciplinary team members as needed to avoid unnecessary effort and cost.

Majority of MRAs for Vertigo Evaluation Overordered, Careful Consideration Needed

Majority of MRAs for Vertigo Evaluation Overordered, Careful Consideration Needed

Evaluation of Vertigo by Magnetic Resonance Angiography: A Clinical Outcomes Study

Evaluation of Vertigo by Magnetic Resonance Angiography: A Clinical Outcomes Study

Various causes and clinical characteristics in vertigo in children with normal eardrums

Objective: The differential diagnosis of vertigo in children is extensive. Otitis media and middle ear effusion could be the most common causes of vertigo in children, but there are some problems in detecting the other causes for vertigo because they are one of most frequent diseases of childhood. The purpose of this study is to review the clinical characteristics and both the audiological and vestibular findings of vertigo in children with normal eardrums, who do not show otitis media or middle ear effusion, and to assist in making a differential diagnosis of vertigo. Methods: The fifty five children (<16 years old) with vertigo, who visited the Department of Otolaryngology, Ajou University Hospital, Suwon, South Korea between January 1995 and December 2001 were selected for this study. These excluded the patients with abnormal eardrums/tympanograms or those that did not perform questionnaires, audiological, or vestibular evaluations. They were retrospectively analyzed for clinical symptoms, vestibular functions, and differential diagnosis. Results: The most common causes for vertigo in children were migraine in 17 (30.9%) and benign paroxysmal vertigo of childhood (BPVC) in 14 (25.5%). Other less frequent causes included four cases of trauma, two cases each of Meniere's disease, delayed endolymphatic hydrops, benign positional vertigo, and one case only for cerebellopontine angle tumor, seizure, acute vestibular neuritis, juvenile rheumatoid arthritis, leaving ten cases (18.2%) as unclassified. Abnormal findings were noted in 13 (23.6%) in pure tone audiogram, 3 (5.5%) in positioning test, 6 (10.9%) in bithermal caloric test, and 36 (65.5%) in rotation chair test. Conclusions: The vertigo in children with normal eardrums, who did not show otitis media or middle ear effusion, was most commonly caused by migraine and BPVC. These findings have shown to be very different from those with adult vertigo. The evaluation of vertigo in children requires a questionnaire for extensive and complete history taking, audiograms and vestibular function tests. And in selected cases, electroencephalography, hematological evaluation, imaging of the brain or temporal bone should be performed.

Benign paroxysmal positional vertigo: Diagnosis and treatment in the emergency department—a review of the literature and discussion of canalith-repositioning maneuvers

Dizziness is a frequent presenting complaint in emergency department patients. Although seen in patients of all ages, it is more prevalent in patients older than 50 years of age. Vertigo represents a subset of dizziness and is defined as an illusion of movement, usually rotational, of the patient or the patient’s surroundings. The illusion of motion may be of oneself (subjective vertigo) or of external objects (objective vertigo). The emergency physician should consider a large differential in the evaluation of vertigo with special attention to whether the vertigo is central or peripheral in origin. [Koelliker P, Summers RL, Hawkins B. Benign paroxysmal positional vertigo: diagnosis and treatment in the emergency department—a review of the literature and discussion of canalith-repositioning maneuvers. Ann Emerg Med. April 2001;37:392-398.]

The Importance of Magnetic Resonance Imaging in the Evaluation of Vertigo and Imbalance

Vertigo and imbalance are believed to be rare manifestations of skull base neoplasms. Patients with skull base neoplasms can present with vague otolaryngological complaints, including diplopia, facial numbness, facial weakness, hearing loss, tinnitus, hoarseness, headache, and otalgia. Physical examination of these patients can sometimes reveal paralysis or paresis of cranial nerves. Magnetic resonance imaging (MRI) is the gold standard for evaluation of cranial nerve involvement in skull base diseases. Vertigo and imbalance can be manifestations of a neuropathy or lesion within the vestibular system and may be subtle or overlooked findings in patients with skull base diseases. The purpose of this article is to review the clinical manifestations of patients presenting with vertigo and imbalance who were found to have skull base neoplasms. We will also highlight the importance of MRI in diagnosis and management of these patients.

Brain stem evoked potentials in childhood neurological diseases.

This review article tries to highlight the most important information available at present on the use of brainstem acoustic evoked potentials (BAEPs) in child neurology. It lists the main original papers with considerable materials and discusses the main territories of use in child neurology according to the diagnosis. Particular emphasis has been placed on the neurodegenerative and neurometabolic disorders, asphyxia, head trauma, brain tumours, autoimmune NS diseases and evaluation of dizziness. It summarizes the importance of BAEPs in child neurology relying, on the data from the literature and the experience and opinion of the author.

The Spectrum of Vertigo in Children

To review the presentation, evaluation, and causes of vertigo in children. A retrospective review of children who presented with the chief complaint of vertigo. Thirty-four children with a chief complaint of vertigo were seen in an ear, nose, and throat clinic during a 2 1/2-year period. Presenting symptoms, diagnostic tests, diagnoses established, and clinical course were evaluated. Otitis media, benign paroxysmal vertigo of childhood, and migraine accounted for the vertigo in 50% of the children. Audiometry, tympanometry, and electronystagmography were the most helpful diagnostic tests, with abnormal results in seven, seven, and six patients, respectively. Of the 19 patients with adequate follow-up, 15 (79%) were improved or asymptomatic at the time of their last visit. Peripheral causes of vertigo, eg, otitis media, were noted most commonly. Evaluation of vertigo should include a complete history and physical examination, an audiogram, and a tympanogram. In select cases, electronystagmography, electroencephalography, and scanning of the brain or temporal bone should be performed. A favorable outcome was noted in most cases.

Evaluation of Vertigo in the Pediatric Patient

Educational objective: To evaluate a pediatric patient with vertigo in a systematic fashion.

The evaluation of dizziness in elderly patients.

Twenty-one elderly patients with dizziness underwent a comprehensive medical and otoneurological evaluation. The majority had vertigo, limited mobility and restricted neck movements. Poor visual acuity, postural hypotension and presbyacusis were also frequent findings. Electronystagmography revealed positional nystagmus in 12, disordered smooth pursuit in 18, and abnormal caloric responses in nine. Magnetic resonance imaging showed ischaemic changes in six out of eight patients. Although dizziness in the elderly is clearly multifactorial, the suggested importance of vertebrobasilar ischaemia warrants further consideration as vertigo has been shown to be a risk factor for stroke.

Should echocardiography be used to screen dizzy patients?

The value of echocardiography in the evaluation of dizziness was studied in 151 consecutive patients. Twenty-two patients, on further review, were found to have related complaints, seizures and syncope mainly, but not dizziness. Twenty-four patients had vertigo, 67 had nonvertiginous dizziness, and in 38 patients, there was insufficient information to categorize the dizziness as being vertigo or nonvertiginous dizziness. When the 22 nondizzy patients were compared with the 129 dizzy patients, the only statistically significant differences were that there were more blacks in the nondizzy group and that the aortic root dimension was, on average, 0.4 cm larger in the nondizzy group. These findings, although statistically significant, appeared to be clinically insignificant. There was, however, a high prevalence of valvular heart disease in both the nondizzy and two of the three dizzy subgroups. In most cases, the valvular abnormality had not been suspected clinically. But in no case was significant information added by echocardiography that helped in patient management. Thus, in the dizzy patient, echocardiography should be reserved for specific cardiac indications and not used as a routine screening test.

The evaluation of dizziness in children

A child with symptoms that relate to the balance mechanism can be a complex diagnostic problem. Often an adequate history is difficult to obtain because of the child's age and limitation of expression. Psychosomatic illness can frequently present as dizziness in children; however, this should not preclude a thorough evaluation. It is the purpose of this paper to outline these possibilities and the characteristics unique to each. The differential diagnosis can be grouped into central (central nervous system) and peripheral (otologic) categories, with a few miscellaneous conditions. A basic evaluation should include a complete neurotologic examination, audiogram and electronystagmogram. An electroencephalogram is frequently a valuable diagnostic adjunct. Further testing should be decided on the basis of the patient's history, examination and prior results. The records of children admitted to Boston City Hospital over a one-year period were reviewed. Of 2,088 pediatric patients, 238 had discharge diagnoses pertinent to the balance mechanism. Of these, 14 had a presenting symptom of dizziness. These cases are analyzed.

Evaluation of dizziness and syncope by 24-hour ambulatory electrocardiography

Evaluation of dizziness and syncope by 24-hour ambulatory electrocardiography

Clinical Evaluation of Vertigo

In attempting to outline the clinical evaluation of these patients with vertigo we have discussed examples which range in order from benign self-limited disease to those requiring emergency surgery or extensive diagnostic evaluation. We sought also to illustrate how the logic of hypothesis testing is generally employed by clinicians in approaching this or other diagnostic problems. The examples were chosen to illustrate the indications for, as well as the limitations of, the various diagnostic modalities--caloric testing, electronystagmography, audiometric testing, roentgenographic and nuclear medicine procedures--which may be employed by the clinician. Most of the skills discussed in our paper, though traditionally accorded to the fields of neurology and otolaryngology, would seem to be fundamental for any general physician, while the problem of vertigo is an example of how common ambulatory problems may require knowledgeable approach to sort self-limited from more serious illnesses as well as to utilize procedures with purpose and efficiency.