Vertigo physical examination

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

Physical Examination

Vertigo Signs 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

Important signs to assess in a patient with vertigo:

• Nystagmus assessment is an important feature to distinguish peripheral from the central cause of vertigo:
  • Nystagmus in Peripheral Cause: horizontal nystagmus with a torsional component.
  • Nystagmus in Central Cause: Could be in any direction horizontal, vertical, or torsional,
• 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 otiticus(vescicles 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.
• Hennebert’s sign, pushing tragus provokes vertigo or nystagmus on the affected side in patients with perilymphatic fistula.