Vertigo physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Physical Examination

• A focal physical examination can help identify the cause of vertigo:
• Neurological exam should assess for cranial nerve palsies, nystagmus and sensorineural hearing loss.
• Nystagmus assessment is an important feature to distinguish peripheral from the central cause of vertigo:
  • Peripheral: Horizontal nystagmus with a torsional component, adaptive.
  • Central: Could be in any direction horizontal, vertical, or torsional, non- adaptive.
• Hearing: Weber or Rinne's test is done in the clinic or at the bedside to determine if it is conductive or sensorineural hearing loss.
• Otoscopic Exam: Can identify cholesteatoma, herpes zoster oticus(vesicles on tympanic membrane), acute otitis media.
• HINTS: Head Impulse, Nystagmus, Test of Skew (cover/uncover test) to identify if the cause of vestibular neuritis is central or peripheral.
• Dix-Hallpike maneuver is used to diagnose benign paroxysmal positional vertigo. Dix-Hallpike maneuver can also differentiate between central and peripheral, the intensity of induced symptom decreases with repeated maneuvers in peripheral but less likely to decrease if the lesion is central in origin.
• Hennebert’s sign, pushing tragus provokes vertigo or nystagmus on the affected side in patients with perilymphatic fistula.

Vertigo features that differentiate peripheral vs central

Peripheral

Central

Intermittent Positional Associated factors (tinnitus, hearing loss, unsteadiness) Nystagmus (delayed, rotatory/horizontal, adaptive) Stops with visual fixation

Non-positional Assosiated factors (other cranial nerves involvement - facial droop/dysarthria) Nystagmus (immediate/delayed, rotatory/horizontal/vertical, not adaptive Does not stop with visual fixation