Vertigo physical examination: Difference between revisions
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=== | == Physical Examination == | ||
===Ear 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 | |||
====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 | |||
===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 | |||
== References == | == References == | ||
{{Reflist|2}} | {{Reflist|2}} | ||
Revision as of 16:39, 1 March 2013
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Risk calculators and risk factors for Vertigo physical examination |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Physical Examination
Ear 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
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
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