Vertigo physical examination

Common physical examination findings associated with vertigo include nystagus hearing impairment , vision changes, and imbalance.

Clinical practice guidelines direct the assessment^[1] using the HINTS, finger rub (for hearing assessment), and maybe STANDING protocol or ABCD² score.

Physical examination of patients with vertigo is usually remarkable for nystagmus, hearing impairment, nausea, imbalance, vision changes.

• Patients with vertigo have variable general appearance depending on the underlying etiology.
• Unsteady gait (cerebellar involvement), sensitivity to motion/light/smell/noise (vestibular migraine) could be observed.

• Blood pressure should be assessed to rule out orthostatic hypotension.
• Hyperthermia could be associated with vestibular neuronitis, herpes zoster oticus, acute labyrinthitis.

• Skin examination of patients with vertigo is usually normal. However, any signs of trauma should be assessed.

• HEENT examination of patients with vertigo is very important. Following examinations should be performed in every patient presenting with vertigo:
  • Otoscopic Exam: Can identify cholesteatoma, herpes zoster oticus(vesicles on tympanic membrane), acute otitis media.
  • Hennebert’s sign, pushing tragus provokes vertigo or nystagmus on the affected side in patients with perilymphatic fistula.^[2]
  • 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.
  • HINTS: Head Impulse, Nystagmus, Test of Skew (cover/uncover test) to identify if the cause of vestibular neuritis is central or peripheral^[3]. This test has higher sensitivity than neuroimaging in ruling out stroke as a cause of acute vertigo.^[4]. Video link at YouTube – https://www.youtube.com/watch?v=VwmrjYuvqtQ
  • Look for evidence of trauma.
  • Nystagmus assessment is an important feature to distinguish peripheral from the central cause of vertigo:^[5]
    • Peripheral: Horizontal nystagmus with a torsional component, adaptive.
    • Central: Could be in any direction horizontal, vertical, or torsional, non-adaptive.
  • Dix-Hallpike maneuver is used to diagnose benign paroxysmal positional vertigo^[6]. Dix-Hallpike maneuver can also differentiate between central and peripheral, the intensity of induced symptom decreases with repeated maneuvers in peripheral but less likely to decrease if the lesion is central in origin.^[7]

• Neck examination of patients with vertigo is usually normal. However, any signs of trauma should be assessed.

• Pulmonary examination of patients with vertigo is usually normal.

• Cardiovascular examination of the patients with vertigo should include heart rate and rhythm, pulse, blood pressure, carotid bruit, orthostatic blood pressure measurement.

• Abdominal examination of patients with vertigo is usually normal.

• Back examination of patients with vertigo is usually normal.

• Genitourinary examination of patients with vertigo is usually normal.

• Neuromuscular examination of patients with vertigo is very important in identifying the underlying etiology:
• Patient is usually oriented to persons, place, and time
• Cranial nerves: strength, sensation, reflexes should be examined.
• Gait imbalance should be assessed by Romberg test and tandem walking for cerebellar function.^[5]

• Extremities examination of patients with vertigo is usually normal.

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