Diagnostic Considerations

On the basis of the patient’s history and physical findings, the examining physician should be able to formulate a differential diagnosis and determine whether the symptoms are likely to be peripheral or central (see the Table below).

Table. Features Differentiating Peripheral from Central Nystagmus (Open Table in a new window)

System or Reflex	Peripheral Lesions	Central Lesions
Oculomotor	Spontaneous nystagmus with eyes closed	Saccades (velocity, accuracy), internuclear ophthalmoplegia, saccadic pursuit, gaze-evoked nystagmus
Vestibulo-ocular reflex (VOR)	Nystagmus without fixation, nystagmus after head shaking, eye-head mismatch, unilateral and bilateral vestibular loss	Hyperactive VOR, failure of fixation suppression (FFS), positional nystagmus, bilateral vestibular loss
Vestibulospinal reflex (VSR)	Cautious gait; normal spontaneous movement; normal, spontaneous, and correct movement	Wide-based gait, minimal spontaneous movement

Differential Diagnoses

Benign Paroxysmal Positional Vertigo
Immune-mediated inner-ear disease
Meniere Disease (Idiopathic Endolymphatic Hydrops)
Migraine Headache
Vestibular Neuritis
Vestibular schwannoma

Workup

Kerber KA, Meurer WJ, West BT, Fendrick AM. Dizziness presentations in U.S. emergency departments, 1995-2004. Acad Emerg Med. 2008 Aug. 15(8):744-50. [QxMD MEDLINE Link].
Saber Tehrani AS, Coughlan D, Hsieh YH, Mantokoudis G, Korley FK, Kerber KA, et al. Rising annual costs of dizziness presentations to U.S. emergency departments. Acad Emerg Med. 2013 Jul. 20 (7):689-96. [QxMD MEDLINE Link].
Olsson Möller U, Midlöv P, Kristensson J, Ekdahl C, Berglund J, Jakobsson U. Prevalence and predictors of falls and dizziness in people younger and older than 80 years of age-A longitudinal cohort study. Arch Gerontol Geriatr. 2012 Sep 18. [QxMD MEDLINE Link].
Trune DR. Ion homeostasis in the ear: mechanisms, maladies, and management. Curr Opin Otolaryngol Head Neck Surg. 2010 Oct. 18(5):413-9. [QxMD MEDLINE Link]. [Full Text].
Navi BB, Kamel H, Shah MP, Grossman AW, Wong C, Poisson SN, et al. Rate and predictors of serious neurologic causes of dizziness in the emergency department. Mayo Clin Proc. 2012 Nov. 87(11):1080-8. [QxMD MEDLINE Link].
Katsarkas A. Dizziness in aging: the clinical experience. Geriatrics. 2008 Nov. 63(11):18-20. [QxMD MEDLINE Link].
van Leeuwen RB, Bruintjes TD. Dizziness in the elderly: diagnosing its causes in a multidisciplinary dizziness unit. Ear Nose Throat J. 2014 Apr-May. 93(4-5):162, 164, 166-7. [QxMD MEDLINE Link].
Lüscher M, Theilgaard S, Edholm B. Prevalence and characteristics of diagnostic groups amongst 1034 patients seen in ENT practices for dizziness. J Laryngol Otol. 2014 Feb. 128(2):128-33. [QxMD MEDLINE Link].
Fakhran S, Alhilali L, Branstetter BF 4th. Yield of CT Angiography and Contrast-Enhanced MR Imaging in Patients with Dizziness. AJNR Am J Neuroradiol. 2012 Oct 25. [QxMD MEDLINE Link].
Murofushi T, Shimizu K, Takegoshi H, Cheng PW. Diagnostic value of prolonged latencies in the vestibular evoked myogenic potential. Arch Otolaryngol Head Neck Surg. 2001 Sep. 127(9):1069-72. [QxMD MEDLINE Link].
Walker MF. Treatment of vestibular neuritis. Curr Treat Options Neurol. 2009 Jan. 11(1):41-5. [QxMD MEDLINE Link].
Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, Tusa RJ, et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2008 May 27. 70(22):2067-74. [QxMD MEDLINE Link].
Honaker J, Samy RN. Migraine-associated vestibulopathy. Curr Opin Otolaryngol Head Neck Surg. 2008 Oct. 16(5):412-5. [QxMD MEDLINE Link].
Lempert T, Olesen J, Furman J, et al. Vestibular migraine: diagnostic criteria. J Vestib Res. 2012. 22(4):167-72. [QxMD MEDLINE Link].
Jen J, Kim GW, Baloh RW. Clinical spectrum of episodic ataxia type 2. Neurology. 2004 Jan 13. 62(1):17-22. [QxMD MEDLINE Link].
von Brevern M, Ta N, Shankar A, et al. Migrainous vertigo: mutation analysis of the candidate genes CACNA1A, ATP1A2, SCN1A, and CACNB4. Headache. 2006 Jul-Aug. 46(7):1136-41. [QxMD MEDLINE Link].
Carlson ML, Tveiten OV, Driscoll CL, Neff BA, Shepard NT, Eggers SD, et al. Long-term Dizziness Handicap in Patients with Vestibular Schwannoma: A Multicenter Cross-sectional Study. Otolaryngol Head Neck Surg. 2014 Oct 1. [QxMD MEDLINE Link].
Sacco RR, Burmeister DB, Rupp VA, Greenberg MR. Management of benign paroxysmal positional vertigo: a randomized controlled trial. J Emerg Med. 2014 Apr. 46(4):575-81. [QxMD MEDLINE Link].
Hamid MA, Samy HM. Vestibular and Balance Rehabilitation. Hamid M, Sismanis A, Eds. Medical Otology & Neurotology. New York, NY: Thieme; 2006.

Media Gallery

Example of Frenzel goggles used for evaluation in neuro-otology clinic.
Typical example of computer and headgear equipment used in neuro-otology clinic.

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Author

Hesham M Samy, MD, PhD Associate Professor of Audiovestibular Medicine, Minia Unversity, Egypt

Hesham M Samy, MD, PhD is a member of the following medical societies: American Academy of Audiology, American Auditory Society, Association for Research in Otolaryngology, Egyptian Society of Otorhinolaryngology

Disclosure: Nothing to disclose.

Coauthor(s)

Mohamed A Hamid, MD, PhD Founder and Medical Director, The Cleveland Hearing and Balance Center; Clinical and Adjunct Professor of ENT, Case-MetroHealth, Medical College of Virginia, and Ain Shams University, Egypt

Mohamed A Hamid, MD, PhD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Otological Society, American Neurotology Society

Disclosure: Nothing to disclose.

Marc Friedman, DO, FAAN Consultant in Otoneurology, The Cleveland Hearing and Balance Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Niranjan N Singh, MBBS, MD, DM, FAHS, FAANEM Adjunct Associate Professor of Neurology, University of Missouri-Columbia School of Medicine; Medical Director of St Mary's Stroke Program, SSM Neurosciences Institute, SSM Health

Niranjan N Singh, MBBS, MD, DM, FAHS, FAANEM is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Headache Society

Disclosure: Nothing to disclose.

Chief Editor

Robert A Egan, MD NW Neuro-Ophthalmology

Robert A Egan, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, North American Neuro-Ophthalmology Society, Oregon Medical Association

Disclosure: Received honoraria from Biogen Idec and Genentech for participation on Advisory Boards.

Acknowledgements

Marc Friedman, DO Chief of Neurology, Parma Hospital, Consultant, Department of Neurology-Neurotology, Cleveland Hearing and Balance Center

Disclosure: Nothing to disclose.

Spiros Manolidis, MD Associate Professor of Otolaryngology and Neurological Surgery, Columbia University

Spiros Manolidis, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Auditory Society, American Head and Neck Society, American Medical Association, Canadian Society of Otolaryngology-Head & Neck Surgery, Society of University Otolaryngologists-Head and Neck Surgeons, and Texas Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

Sections Dizziness, Vertigo, and Imbalance
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Dizziness, Vertigo, and Imbalance Differential Diagnoses

Diagnostic Considerations

Differential Diagnoses

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