Taking a History from a Dizzy Patient
To offer simple advice to clinicians trying to decipher the complexities of balance disorders. The page applies to differentiating the major causes of ear related dizziness.
If the ear were the only cause of balance disorders the problem of diagnosis based upon history would be very much simplified. Unfortunately for the busy clinician, multiple bodily systems can contribute to a sense of
poor balance. In fact the cause may be due to eye, ear, neurological, psychiatric, cardiovascular, orthopaedic, drug related or multiple causes.
Multiple causes are especially present in the elderly and their problems are compounded by the natural decline in muscle strength, nerve conduction velocity, mobility of the joints, age related decline in eye and inner ear function, not to forget the drug side-effects that elderly patients must bear.
This page concentrates on a few simple rules that help to point the clinician in the right direction but does not give an exhaustive list of pertinent questions to follow. Furthermore, it focusses largely on ear related causes and a full history will include enquiry about drugs, neurological, cardiovascular, psychological and other potential contributors.
A word about words
“When I use a word,” Humpty Dumpty said, in rather a scornful tone, “it means just what I choose it to mean—neither more nor less.” “The question is,” said Alice, “whether you can make words mean so many different things.” “The question is,” said Humpty Dumpty, “which is to be master—that’s all.” LEWIS CARROLL, Through the Looking-Glass, chapter 6, p. 205 (1934).
We have generally avoided the pretension of using quotes to introduce pages on this website but the one above is really quite pertinent. The problem of the words we use and their personal meanings is especially
relevant when meeting patients with a balance disorder.
Patients often have great difficulty in describing their symptoms to any one else and there are good reasons for this. First amongst these is that the meanings of the words used is not shared between the patient and the doctor in the same way.
A patient may use the word 'vertigo' to describe a number of very different sensations. Doctors define vertigo as a hallucination of movement (such as rotation) while patients may use it to describe light-headedness, poor equilibrium or a falling sensation. We have no common language that conveys instant understanding of the patient's symptoms. This is in distinction to colours, for example, where we can all more or less agree what orange looks like.
Research into the words patients use to describe their problem has found that there is no link between the word they use and the final diagnosis. Patients that say, 'I have vertigo', may just as easily have orthostatic hypotension as Ménière's disease. A patient who is 'dizzy' may eventually be diagnosed as vestibular neuritis, BPPV, or stroke.
History taking should, then, focus less on what the patient means and more on other features. These are described below.
It is also of fundamental importance that patients experience their symptoms differently. One patient may be disabled by a symptom that would be shrugged off by another. So, the severity of the symptom, can be misleading by itself.
Timings, Triggers, and Associations
Instead of dwelling too much on the way the patient describes their balance symptoms it can be useful to elicit information about timings - how long the symptoms lasts, triggers - what makes the symptom come on or worsen them, and associations - what else happens at the same time?
While patients struggle to describe their symptom in ways that are meaningful and useful for the clinician, they are much better at identifying timings and triggers. In general the following timings apply to ear related causes of vertigo:
1. Benign paroxysmal positional vertigo (BPPV) - seconds (sometimes described as a minute by the patient who may lose a sense of the actual time while they are suffering the symptom)
2. Ménière's Disease - hours or up to a day
3. Vestibular neuritis - days or weeks
4. Labyrinthitis - days or weeks
5. Persistent postural perceptive dizziness (PPPD) - present on most days for 3 months
Of course, one can't diagnose the problem based upon timings alone but they give a valuable pointer.
Triggers such as movement causing symptoms can be very helpful as long as the clinician is aware of an important distinction between movement causing symptoms and movement exacerbating symptoms.
1. BPPV - the symptoms of BPPV are triggered by movement, that is to say, when the patient is not moving the symptoms are absent and when they lie down, roll in bed, or look up the symptoms are triggered.
2. Ménière's, Vestibular neuritis, labyrinthitis - In all of these during an attack, movement makes the symptoms worse. Typically, the patient prefers to remain still for fear of making their symptom worse
3. PPPD - only present when the patient is standing or walking
4. Orthostatic hypotension - symptom is triggered by standing up or getting out of bed in the morning and doesn't happen when lying down or when sitting down
5. 'Visual vertigo', dizziness that is brought on by visually complex environments (like supermarkets) or movement in the visual environment (scrolling screens, patterned wallpapers or carpets) - typical of poor recovery after vestibular failure. Also required for PPPD.
Associations are symptoms that accompany the balance disturbance. Symptoms that come just before the dizziness, during the dizziness, or immediately afterwards can give a strong pointer to the underlying cause:
1. Hearing loss, aural pressure sensation (aural fullness) and tinnitus - when these occur with the attack of vertigo they point to an ear cause.
2. Headache - a migraine like headache before, during or after a bout of vertigo suggests migraine associated vertigo as the diagnosis
3. Slurring of speech, diplopia, other visual disturbances, facial weakness, hemianaesthesia with or without hemiparesis, any other 'neurological' symptom synchronous with dizziness - consider neurological causes and exclude a stroke if this is an acute presentation
4. Palpitations - consider a dysrhythmia as a cause of dizziness
5. Shortness of breath, circumoral paraesthesia, paraesthesia in the fingers or toes, palpitations - with dizziness may suggest hyperventilation (or a strong emotional response to the vertigo)
Of course, the complex task of making a diagnosis from a history cannot be captured with a simple formula of questions such as is suggested above. However, the principles above are useful and will often give far more information than clinical testing, especially if the patient is well on the day that you see them.
In the acute situation, however, the clinician faced with a patient with acute onset vertigo must make a careful examination of the eye movements and of the ear and other neurology. The presence and type of nystagmus can greatly assist in diagnosis so carefully examining and recording abnormalities in eye movement is paramount if a diagnosis is to be achieved.
This is especially so when trying to differentiate a posterior fossa stroke from inner ear disease. Getting the right diagnosis here is crucial as it determines the treatment pathway that the patient must enter and the speed of management of someone with a stroke determines their outcome.
Please see the page on differentiating a stroke from benign vestibular disease here.