Vertigo physical examination

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

Physical Examination

• Vestibular exam

  • Nystagmus

    • Peripheral lesions:

      • Horizontal +/- torsional component, never vertical
      • Fast phase toward the normal ear
      • Never reverses direction
      • Suppressed by visual fixation
      • (Prevent fixation via Frenzel lenses -> increased nystagmus)

    • Central lesions

      • Can be in any direction
      • May reverse direction when patient looks in direction of slow phase
      • Not suppressed by visual fixation

  • Provocative maneuvers

    • Dix-Hallpike (Baranay): Patient sitting on exam table

      • Lies down with head extending over table edge, 45° to one side
      • Position change can occur slowly; should be held for > 30 sec
      • Repeat with head turned 45° to opposite side, then without turning head
      • Peripheral lesion:

        • 2-20 sec latency before onset of nystagmus
        • Duration of nystagmus < 1 minute
        • Fatigues with repetition of maneuver
        • One type nystagmus (upbeat and torsional)
        • Severe vertigo (spinning toward normal ear)

      • Central lesion: no latency before onset of nystagmus

        • Duration of nystagmus > 1 minute
        • No fatiguability
        • Direction may change with head position
        • Less severe, if any, vertigo

• Neurologic exam

  • Cranial nerves
  • Motor/sensory deficits,
  • Deep tendon reflexes (DTRs)
  • Cerebellar signs?
  • Central lesion

• Romberg

  • Unilateral peripheral lesion -> patient leans/falls to side of lesion, but able to walk
  • Acute cerebellar lesion -> patient unable to walk without falling; variable direction of fall

• Hearing

  • Test gross hearing with whisper/finger tap
  • If asymmetric hearing loss:
  • Rinne test to confirm sensorineural (vs. conductive) loss

    • Air>bone conduction with sensorineural loss

  • Tympanum membrani (TM) exam to rule out acute or chronic otitis media as etiology
  • Speech discrimination to assess cochlear or retrocochlear

    • Identification of < 20% of 10 2-syllable words whispered into affected ear suggests retrocochlear lesion (acoustic neuroma)
    • Identification of > 70% of words = cochlear disease
    • Identification of 20-70% = indeterminate (audiology)

  • Audiometry referral to confirm hearing loss