Vestibular Case History


Written by Travis M. Moore
Last edited 20-Sep-2019


Utility of the Case History

The case history is your most powerful tool for vestibular assessment. While taking a case history, the clinician asks a series of pointed, specific questions that are driven by the patient's complaints. After the chart review and case history are complete, the main reason to do diagnostic testing is to confirm or disprove your initial diagnosis. This might sound surprising at first. After all, the whole point of diagnostic testing to is arrive at a diagnosis, right? Can a case history really be that useful?

Yes! Recall that the vestibular system is involved with several other sensory systems (e.g., vision and proprioception/ somatosensation) and communicates with a wide range of central nervous system structures (e.g., cerebellum, spinal cord, brainstem) and peripheral structures (e.g., extraocular and neck muscles). Imbalance can result from a problem with any of those communications.

A case history allows us to rule out certain underlying causes and types of imbalance. As we rule out more and more possible etiologies (i.e., what causes a sign or symptom), eventually we're left with a pretty darn good idea of what the issue is. This technique works because different types of balance/dizziness are associated with specific signs and symptoms and damaged structures.

Another way a case history helps to home in on the problem is by providing specific language. It's not very often that a person has to describe feelings of vertigo, disequilibrium, and lightheadedness. By asking specific questions you can offer descriptive language that the patient might not have. It is vital not to lead the patient, but rephrasing with words that help distinguish lightheadedness (e.g., a floating sensation) from disequilibrium (e.g., unsteadiness) gives the patient a chance to confirm or deny your diagnostically useful terminology.



Questions to Ask During Case History

There are several categories that will help to narrow down the likely cause of a patient's imbalance/dizziness. Below are the broad categories taken from the 20081 (first edition) and 20162 (second edition) clinical textbooks edited by Jacobson and Shepard; and the 2001 (third edition) book written by Baloh and Honrubia3.

Table 1. Description of Symptoms
Patients can experience a wide range of sensations related to their dizziness, and it is important to record their subjective experiences. Below are classifications for several types of sensations.

Vertigo
The actual illusion of movement. Sometimes referred to as true vertigo or room-spinning vertigo. Patients can experience the perception that the room is spinning, or that they are spinning themselves. Vertigo can be incapacitating and lead to severe nausea and vomiting.
Peripheral vs Central Vertigo
Peripheral vertigo originates in the actual vestibular organs themselves. This means the brain is getting a direct signal that a person is rotating, which means nausea and vomiting are common. Peripheral vertigo is also typically relatively short-lived. Due to the proximity of the vestibular organs to the cochlea, peripheral insults can also lead to hearing loss and/or tinnitus.

Central vertigo is typically less severe than peripheral vertigo, and can last significantly longer. Serious signs include the inability to stand or walk, which may suggest the presence of a life-threatening situation, such as a cerebellar hemorrhage3.
Presyncope and Syncope
Presyncope refers to the sensations of lightheadedness, dizziness/vertigo, and unsteadiness that can occur just before fainting. Accordingly, this is also known as near-faint dizziness. Syncope refers to an outright faint, where the patient loses consciousness for a moment. However, presyncope and syncope aren't necessarily related. Krahn et al. (2001)4 showed that syncope is more often related to a heart arrhythmia (altered timing of the heartbeat) than to presyncope. Presyncope and syncope are often related to reduced blood to the brain, which can be a life-threatening condition if left untreated.3
Lightheadedness
Patients reporting sensations such as lightheadedness, faintness, or floating may be experiencing a prolonged lack of oxygen. After a short period of hyperventilation, it is possible to maintain the lack of oxygen to the brain without the quick, deep breathing. Lightheadedness is also a common complaint accompanying psychiatric disorders, such as agoraphobia, panic attacks, and acute/chronic anxiety.
Disequilibrium
Patients report feeling imbalanced or unsteady while walking. The sensation does not occur with head movements alone. There may be a lack of sensation in the legs and feet. Both unilateral and bilateral impairment to the vestibular organs can result in disequilibrium/unsteadiness (e.g., oscillopsia).



Table 2. Duration of Symptoms
How long the vertigo/dizziness lasts is an extremely useful piece of information. We can rule out several types of vertigo/dizziness based on the time course.

Seconds
Benign paroxysmal positional vertigo (BPPV) commonly lasts less than one minute. Certain types (cupulolithiasis) can last longer, but are more rare.
Minutes to Hours
Vertigo associated with Meniere's disease can last up to several hours. Meniere's disease is also accompanied by a feeling of fullness in the ear, tinnitus, and fluctuating hearing loss.

Perilymphatic fistulas can produce vertiginous spells that last for durations similar to Meniere's disease. These tiny holes allow perilymph to leak, which changes the pressure in the inner ear.

Jacobson and Shepard (2016)2 state that vertigo due to a transient ischemic attack (TIA) can last up to 20 minutes. Note that the symptoms experienced during a TIA completely disappear after the attack. While this is good news, TIA is also an indicator of an impending full stroke5.
Hours to Days
Vestibular neuritis (labyrinthitis if accompanied by hearing loss) is one of the few diseases that affects the peripheral vestibular system, but has a long duration.

Vestibular migraine can result in symptoms lasting from minutes to days.

A stroke in the region around the vestibular nuclei (posterior circulation) can cause long-lasting vertigo by damaging vestibular neural tissue through ischemia (lack of blood).



Table 3. Precipitating Factors
Inquiring about situations or events that commonly trigger dizziness/vertigo can provide insight into the underlying mechanism.

Movement
Turning the head left or right can trigger BPPV by causing the displaced otolith to move. Bending over (e.g. while gardening) and rolling over in bed are other possible triggers for BPPV. Quick head turns can also cause symptoms in patients who are not dynamically compensated, and sometimes even after compensation is complete. It is also possible to pinch arteries when the head is tilted up, restricting blood flow and causing dizziness.
Pressure Changes
Straining (e.g., lifting weights), sneezing, and blowing one's nose are examples of increasing the pressure in the middle ear, which impacts the pressure in the inner ear. Pressure changes can also include changes in altitude and even weather patterns. Patients with a perilymphatic fistula or Meniere's disease may be particularly susceptible to changes in pressure.
Loud Noises
Dizziness brought on by a loud noise is referred to as Tullio's phenomenon. Patients with SSCD, perilymph fistula and Meniere's disease may have this complaint.
Changes to Daily Living
This is a broad category that includes starting/stopping/changing a medication, changing diet, and an increase in stress (e.g., starting a new job). Patients sensitive to these changes common present with vestibular migraine and/or Meniere's disease.



Table 4. Associated Symptoms
Several types of dizziness/vertigo present with more than just vestibular symptoms. The presence of other sensations is an important piece of information that can help localize the lesion to a more specific anatomical region.

Inner Ear
Hearing loss, tinnitus, fullness/pressure, pain
Cerebellopontine Angle
Hearing loss, tinnitus, facial weakness/numbness, incoordination
Brainstem
Double vision (diplopia), trouble speaking due to problems with the muscles used in speech (dysarthria), numbness or weakness in the extremities, drop attacks
Cerebellum
Imbalance, lack of coordination (e.g., ataxia)



Table 5. Medical History
Some types of dizziness/vertigo have a genetic origin, while others are associated with previous surgeries, medications, and other disease. A thorough medical history can save significant time, which is why a chart review should always happen (when available) before seeing a patient.

Genetic Predisposition
Vestibular migraine, Meniere's disease, neurofibromatosis, otosclerosis (if it invades the labyrinth), and diseases that lead to degeneration of the cerebellum and spinal cord.
Ear Surgery
Perilymphatic fistulae may arise during surgery. More obvious indicators include labyrinthectomy and nerve resection.
Vascular Disease
Vascular disease can also fit under the "genetic" category, but these pathologies also involve environmental factors6. Many types of dizziness/vertigo are due to problems maintaining blood pressure and stroke.
Head Trauma
Car accidents, concussions and similar traumas can lead to (severe) BPPV and SSCD.
Medication
The number of medications listing "dizziness" as a side effect is too many to count. However, there are some particularly important medications to consider when taking a medical history. For example, medications for blood pressure, anxiety, depression, muscle pain, and diabetes can lead to issues with dizziness.



Summary

We have covered a lot of information in this module, and that should help to drive home just how important a vestibular case history is. Without the information necessary for a case history it is extremely difficult, if not impossible, to predict likely causes of a patient's complaints. In fact, without this specialize vocabulary it would be impossible to differentiate between the wide range of symptoms found in the balance clinic. Lucky for your patients, you have taken the time to learn the material on this page!


Test Your Understanding

BPPV. Turning the head to check for traffic activates the patient's BPPV. The left side is likely involved because the symptoms only occur when the patient looks left. Despite a few hours of feeling wiped out, the true sensation of vertigo lasted under 1 minute.
Perilymphatic fistula. While the otosclerosis was mild, a fistula occurred during surgery. While flying the patient experienced pressure changes which triggered the symptom of dizziness.

Next Topic: Bedside Assessment

REFERENCES

1Jacobson, G. P., & Shepard, N. T. (2008). Balance Function Assessment and Management (First ed.): Plural Publishing.
2Jacobson, G. P., & Shepard, N. T. (2016). Balance Function Assessment and Management (Second ed.): Plural Publishing.
3Baloh, R. W., & Honrubia, V. (2001). Clinical Neurophysiology of the Vestibular System (Third ed. Vol. 18): Oxford University Press, Inc.
4Krahn, A. D., Klein, G. J., Yee, R., & Skanes, A. C. (2001). Predictive value of presyncope in patients monitored for assessment of syncope. American heart journal, 141(5), 817-821.
5Hwang, J., Ho, H., Hsu, M., et al. (2011). Effect of transient ischemic attack on hearing thresholds of older subjects. Audiology and Neurotology Extra, 1(1), 1-8. 6Kochanek KD, Xu JQ, Murphy SL, Miniño AM & Kung HC. (2011). Deaths: final data for 2009. National Vital Statistics Report, 60(3).
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