Overview of Dizziness in Practice

Overview of Dizziness in
P r a c tic e
a, a b
Heather M. Weinreich, MD, MPH *, Emma Martin, MD , Yuri Agrawal, MD, MPH
KEYWORDS
Vertigo Screening questionnaire Multidisciplinary clinic Falls
KEY POINTS
About 50% of patients presenting to an otolaryngology clinic have a neuro-otologic
condition.
Evidence-based screening tools and questionnaires should be used to efficiently catego-
rize patients based on symptoms.
Vestibular testing is not diagnostic but can be used to evaluate the function of the semi-
circular canals and otolith organs as well as compensation for any loss of function.
The creation of a multidisciplinary clinic to aid in diagnosis and management of dizzy pa-
tients is recommended.
High-risk patients should be screened for falls.
INTRODUCTION
Dizziness can be a challenging chief complaint for many clinicians, including otolaryn-
gologists. The key to seeing these patients is to have a plan. This article provides an
overview of evidence-based practices on how to screen dizzy patients before being
scheduled, how to efficiently move patients through the clinic, and strategies for man-
aging a dizzy clinic.
PREVALENCE/INCIDENCE
Annually, 3% to 4% of all patients who present to an emergency department (ED) have

a chief complaint of dizziness,1 whereas for primary care, annual visits range from 1%
to 15.5%.2 For emergency medicine alone, this translates to between 3.9 million and
5.2 million visits per year.3
a
Department of Otolaryngology Head and Neck Surgery, University of Illinois at Chicago, 1855
West Taylor Street, Chicago, IL 60612, USA; b Department of Otolaryngology Head and Neck
Surgery, Johns Hopkins University, 601 North Caroline Street, 6th Floor JHOC, Baltimore, MD
21287, USA
* Corresponding author.
E-mail address: hweinre1@uic.edu
Twitter: @yuriagrawal (Y.A.)
Otolaryngol Clin N Am 54 (2021) 839–852

https://doi.org/10.1016/j.otc.2021.05.008 oto.theclinics.com
0030-6665/21/ª 2021 Elsevier Inc. All rights reserved.
Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de
ClinicalKey.es por Elsevier en septiembre 17, 2021. Para uso personal exclusivamente. No se
permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos
reservados.
840 Weinreich et al
Between 9% and 13% of dizzy patients seen in general practice are referred to spe-
cialty clinics.4 Of those dizzy patients, 48% to 50% have an ear-related diagnosis,
whereas the rest are neurologic, medical, psychological, or unknown.5,6
NATURE OF THE PROBLEM
Approximately 50% of dizzy patients evaluated in an otolaryngology clinic are true

neuro-otologic patients.5,6 For many clinicians, the vestibular system is considered
almost like a mysterious organ, perceived as too complicated to understand and
poorly taught in medical school and residencies.
In many cases, vertigo is incorrectly considered a diagnosis, not a symptom. There
are also many common misconceptions regarding dizziness, as noted in Table 1.7
Inappropriate imaging is often obtained and patients are started on antiemetics
such as meclizine. Even though noncontrast head computed tomography (CT) scans
have low sensitivity in detecting ischemic strokes and are not recommended for ruling
out stroke in patients presenting with vertigo,8 the use of CT imaging in evaluating
dizzy patients presenting to an ED has increased from 9.4% to 37.4%.9
Meclizine, an antiemetic thought to work through antagonism of H1 receptors, is a
commonly prescribed drug for dizziness. However, this drug has the potential for con-
sequences, with more than 50 drug interactions, and, for patients older than 65 years
old, Beers criteria should be applied.10 These criteria include lists of medications for
which the potential risks may be greater than the potential benefits for people aged
65 years and older. In addition, meclizine is prescribed in cases where a diagnosis
is unknown or inappropriately in cases where the diagnosis is known, such as benign
paroxysmal positional vertigo (BPPV). One author (H.W.) reviewed more than 1000 pa-
tients diagnosed with BPPV at her institution, and 55% of patients received at least 1
prescription for meclizine.
Therefore, given these misconceptions, the medical community sends dizzy pa-
tients to otolaryngology. Therefore, the otolaryngologist’s job is to:
1. Ensure the patient is not having a critical issue such as a stroke or cardiac
arrhythmia
2. Rule in all the neuro-otologic diseases such as BPPV, Meniere disease, vestibular
neuritis, and labyrinthitis
3. Refer to the appropriate specialty if not neuro-otology (eg, neurology)
4. Further work up, manage, and treat neuro-otologic conditions
DISCUSSION
Clinic workflows and options vary based on available personnel, testing, and associ-
ated specialists (Fig. 1).
Creating a High-Yield Patient Population

Screening is a critical step in ensuring neuro-otologic patients are being appropriately
scheduled. If possible, screen referrals for vertigo and dizziness before scheduling.
Although system dependent, the neuro-otologist or a team can perform this. Review-
ing documentation to ensure neurologic or cardiac causes have been ruled out, dis-
cussing the patient with the referring clinician, or requiring completion of screening
questionnaires can help facilitate getting the patient to the right specialist. These
questionnaires may include demographic data; description of the dizzy episodes,
including when and how long episodes last; otologic and migraine symptoms; and
prior testing. Zhao and colleagues11 provide an example.
reservados.
Overview of Dizziness in Practice 841
Table 1
Ten pitfalls and pearls in the diagnosis of stroke in acute dizziness and vertigo
Pitfall Pearl Notes

True vertigo implies an Focus on timing and triggers, Cerebrovascular disorders
inner ear disorder rather than type frequently present with true
vertigo symptoms33,34
Worse with head Differentiate triggers from Acute dizziness/vertigo is
movement implies exacerbating factors usually exacerbated by head
peripheral movement, whether
peripheral or central35
Auditory symptoms Beware auditory symptoms of Lateral pontine and inner ear
imply a peripheral vascular cause strokes often cause tinnitus
cause or hearing loss36–38
Diagnose vestibular Inquire about headache Sudden, severe, or sustained
migraine when characteristics and pain in the head or neck may
headaches associated symptoms indicate aneurysm,
accompany dissection, or other vascular
dizziness disorder35; photophobia
may point to migraine39
Isolated vertigo is Some TIA definitions do not Isolated vertigo is the most
not a TIA symptom recognize certain transient common vertebrobasilar
vertebrobasilar neurologic warning symptom before
symptoms (including stroke11,40; it is rarely
isolated vertigo) as TIAs diagnosed correctly as a
vascular symptom at first
contact7,11
Strokes causing Focus on eye examinations: Fewer than 20% of patients
dizziness or vertigo VOR by head impulse test, with stroke presenting with
have limb ataxia or nystagmus, eye alignment AVS have focal neurologic
other focal signs signs.41,42 NIH stroke scales
of 0 occur with posterior
circulation strokes
Young patients have Do not overfocus on age and Vertebral artery dissection
migraine rather vascular risk factors. mimics migraine closely43;
than stroke Consider vertebral artery young patients aged 18–44 y
dissection in young patients with stroke are 7-fold more
likely to be misdiagnosed
than patients aged >75 y9
CT is needed to rule Intracerebral hemorrhage Only 2.2% (n 5 13/595) of
out cerebellar rarely mimics benign intracerebral hemorrhages
hemorrhage in dizziness or vertigo presented with dizziness or
patients with presentations vertigo and only 0.2% (n 5 1
isolated acute out of 595) presented with
dizziness or vertigo isolated dizziness44
CT is useful to search Recognize the limitations of Although some retrospective
for acute posterior imaging, especially CT studies45,46 suggest CT may
fossa stroke be up to 42% sensitive,
prospective studies suggest
the sensitivity is no higher
than 16%13,47
(continued on next page)

reservados.
842 Weinreich et al
Table 1
(continued )
Pitfall Pearl Notes
A negative MRI-DWI Recognize the limitations of MRI-DWI in the first 24 h misses
scan rules out imaging, even MRI-DWI 15% to 20% of posterior
posterior fossa stroke fossa infarctions.12 MRI-DWI
sensitivity for brain stem
stroke is maximal 72–100 h
after infarction.48
Labyrinthine strokes are not
visible
Abbreviations: AVS, acute vestibular syndrome; CT, computed tomography; DWI, diffusion-
weighted imaging; NIH, National Institutes of Health; TIA, transient ischemic attack; VOR,
vestibulo-ocular reflex.
From Saber Tehrani AS, Kattah JC, Kerber KA, et al. Diagnosing stroke in acute dizziness and ver-
tigo: Pitfalls and pearls. Stroke. 2018;49(3):788-795. https://doi.org/10.1161/STROKEAHA.117.
016979 [doi], with permission.
Several studies have shown the predictive power in using such tools. Zhao and col-
leagues11 found that certain questions provide highly predictive accuracies in diag-
nosing migraine, BPPV, and Meniere disease.11 In a similar study, Friedland and
colleagues6 found a predictive accuracy of 71% in using a subset of questions to
create a model for BPPV, Meniere disease, and vestibular migraine. Using this pub-
lished formula, Britt and colleagues12 validated this in a separate population showing
predication of BPPV. Even using a simple 2 2 algorithm, Kentala and Rauch13
showed that almost 60% of neuro-otologic diagnoses can be identified by assessing
the association of hearing loss and duration of vertigo episode. Given the high predict-
ability for identifying BPPV, clinic workflow could include sending these patients to
physical therapy for repositioning maneuvers before requiring a visit with the otolaryn-
gologist (see Fig. 1). Given the labor-intensive nature of screening, groups are trying to
put this into artificial intelligence and integrate it into electronic medical records.14
Schedule Appropriately
Once an appropriate referral has been identified, the next step is to schedule. It would
be difficult to get through a new dizzy patient visit in 5 minutes. Therefore, it is best to
create a clinic schedule that allows adequate time with patients but not at the expense
of running an efficient clinic. Suggestions include:
Fig. 1. Examples of clinic workflows. (A) Patient is scheduled for audiometric and vestibular
testing before seeing otologist. Pending examination and testing, the otologist may refer to
additional services. (B) The patient is evaluated first by the otologist. If examination and his-
tory are consistent with BPPV, patient is referred to physical therapy (PT). Audiometric and/
or vestibular testing may be obtained or the patient may be referred to other services if
diagnosis is not consistent with neuro-otologic condition. (C) Patient is screened. If history
is consistent with BPPV, patient is referred to PT. Pending examination and history, audio-
metric and/or vestibular testing may be obtained, or the patient may be referred to other
services if diagnosis is not consistent with neuro-otologic condition.
reservados.
Performing formal time studies on current workflows to capture the time it takes
to evaluate and follow up new patients.
Using tools such as process maps and value-stream maps to visualize where
bottlenecks may occur or tasks that can be streamlined.
Establishing blocks of time in schedules for patients specifically with dizzy com-
plaints. This process can also include limiting the number of patients presenting
with a complaint of dizziness.
Creating a dizzy clinic that only evaluates or follows up with patients that have a
complaint of dizziness.
Selectively Refer to Vestibular Testing

Once scheduled with an appointment, there are 2 schools of thought on whether to
obtain vestibular testing before the visit or after being evaluated. One of the authors
(Y.A.) obtains testing beforehand and the other (H.W.) determines the need for testing
after evaluation. There are pros and cons to either approach (Table 2).
Regardless of when testing is obtained, clinicians should be thoughtful about why
they are ordering testing. Vestibular testing is not diagnostic. Testing evaluates the
status of the inner ear, which can be used to understand the disorder causing the pa-
tient’s symptoms, examination findings, and can support or negate a diagnosis
(Table 3).
Given the lack of evidence and guidelines for testing, there is significant variation in
the use of vestibular testing. In a cross-sectional review of Medicare beneficiary
claims, Adams and colleagues15 found that most caloric tests were billed by audiolo-
gists and otolaryngologists, whereas primary care physicians and neurologists billed
the largest proportion of rotary chair tests compared with other specialists. Within
otolaryngology, academic practices are 15 times more likely to obtain vestibular
testing at the initial visit compared with nonacademic practices.16
Table 2
The pros and cons to obtaining vestibular testing before or after clinical evaluation
Testing Before Evaluation Testing After Evaluation

Pros Pros
Status of inner ear known before Improves access to clinic by avoiding bottleneck
the visit of testing
Clinic visit: able to perform a Avoids unnecessary testing and costs
directed history, physical Patient may be more likely to complete testing
examination after seeing clinician
More efficient for patient
(does not have to return for testing)
Determine need for imaging
Narrow differential before visit
Cons Cons
Can create a bottleneck for Multiple visits for patient
scheduling and limit patient May not want to come back for testing
access
Insurance many not cover if no
diagnosis
After testing, risk loss to follow up
Patients may also refuse testing
May obtain unnecessary testing
and costs

reservados.
844 Weinreich et al
Table 3
Common types of vestibular test
Test What Does It Test? Physiology Pathophysiology

cVEMPs Saccule and inferior Measures EMG activity SCDS
vestibular nerve from the
sternocleidomastoid
muscles following
vestibular stimulation
with brief pulses of
sound. Manifestation of
the vestibulocollic reflex:
from activation of the
vestibular nerve, the
vestibulospinal tract, the
accessory nerve and, the
sternocleidomastoid
muscle. cVEMP is a
measure of the inhibitory
response on the
ipsilateral side
oVEMP Utricle and superior Extraocular muscles are SCDS
vestibular nerve part of the VOR.
Measures EMG activity of
VOR following activation
of the vestibular nerve,
transmitted possibly via
the medial longitudinal
fasciculus, the
oculomotor nuclei and
nerves, and the
extraocular muscles.
oVEMP is a measure of
the excitatory response
and contralateral side
Rotary chair Horizontal semicircular SCCs are arranged in push- Bilateral
SCCs (rotating in pull pairs; eg, rotation to horizontal
horizontal plane) and the right increases the hypofunction
their contribution to firing rate of the right,
the VOR whereas it decreases
firing rate of left SCC. If
the stimulus is fast
enough, 1 SCC goes into
an inhibitory cut off,
whereas the other SCC
further increases firing
(continued on next page)

reservados.
Table 3
(continued )
Test What Does It Test? Physiology Pathophysiology
Head VOR SCCs send information on Vestibular
impulse head movement hypofunction;
test (excitatory or inhibitory SCDS
to vestibular nerve,
which transmits to
vestibular nucleus).
Causes excitation of
contralateral abducens
nucleus and inhibition of
ipsilateral abducens
nucleus, which then
communicate with lateral
rectus muscles via
abducens nerve and
other EOM via medial
longitudinal fasciculus
and oculomotor nerve.
Lateral and anterior
canals send information
via superior vestibular
nerve. Posterior canals
send information via
inferior vestibular nerve
Calorics Horizontal canal Irrigation of warm or cold Vestibular
water or air into the hypofunction;
external ear canal. When SCDS
the endolymph is
warmed (by air or water),
an excitatory response
occurs in the lateral SCC.
When a cold temperature
is applied, an inhibitory
response occurs
Dix-Hallpike Evaluate for BPPV; Detached otoliths, free BPPV
otoliths within floating in endolymph of
posterior semicircular posterior semicircular
canal canal, create movement
within fluid as the head is
tilted posterior, leading
to deflection of the
cupula
Abbreviations: cVEMP, cervical evoked myogenic potentials; EMG, electromyography; EOM, extra-
ocular muscles; oVEMP, ocular evoked myogenic potentials; SCC, semicircular canal; SCDS, superior
semicircular canal dehiscence syndrome.
Obtain a History
Having a process to efficiently obtain a history is critical for time. The diagnosis lies in
the history and where the clinician should spend time. It is also where a clinician can
lose time. Strategies include:
As discussed earlier, usage of questionnaire sent out before the appointment and
review can help facilitate efficient information gathering. This approach allows
reservados.
846 Weinreich et al
review of the history as well as an interview that focuses on clarifying with a tar-
geted examination.
Asking high-yield evidence-based questions. Goebel17 examined the grouping of
symptoms with the highest predictive value (Table 4), including:
Establishing whether they truly have vertigo versus other sensations (eg, syn-
cope). Vertigo is defined by the American Academy of Otolaryngology’s Equi-
librium Committee as the “sensation of motion when no motion is occurring
relative to earth’s gravity.”18
How long the vertigo lasts: seconds, minutes, hours, or constant for days?
Is it triggered by head position?
Presence or absence of hearing loss or changes in hearing.
Associated symptoms: headaches, visual changes.
What makes it better worse: vestibular suppressants, sleep, busy visual fields?
Focusing on getting the information needed to essentially place patients into 1 of
4 peripheral vestibular groups: BPPV, Meniere disease, vestibular migraine, and/
or unilateral/bilateral vestibular loss. These elements of the history are important
for:
BPPV: duration and positional nature
Meniere disease: associated or prior known sensorineural hearing loss and
otologic symptoms
Vestibular migraine: personal and family history of migraine/headache, associ-
ated migraine symptoms (eg, photophobia/phonophobia), motion sickness
Superior canal dehiscence: dizziness associated with sound or pressure, ear
fullness, and pulsatile tinnitus.
Clinicians also need to evaluate for red-flag symptoms and signs that can indicate a
central process. These signs include, but are not limited to:
Ataxic gait
Diplopia, vision loss, or other visual changes
Cranial nerve deficits
Slurred speech
Paresthesia of face, head, or body
Muscle weakness, incoordination
Develop a Network of Collaborators and Specialists

Even with the best screening tools, patients with non–neuro-otologic disease pro-
cesses may find their way into the otolaryngologist’s clinic. Therefore, it is critical to
develop a network of specialists to whom patients can be referred for definitive treat-
ment. Table 5 provides a brief list of specialists.
Multidisciplinary Teams and Falls Clinic

The authors strongly recommend a team approach and developing a multidisciplinary
group to assist in evaluating and managing dizzy patients. The cause of the dizziness
may not be clear, it may involve peripheral and central pathophysiology, and treatment
may require rehabilitation or the need to address associated anxiety or depression.
Between 42.5% and 68% of patients with vertigo may have an associated psychiatric
comorbidity, including anxiety and depression.19 Associated disorders can have an
impact on therapy and recovery. Patients with anxiety and depression take longer
to compensate with vestibular therapy and may not achieve outcomes as satisfactory
as those without.20
reservados.
Table 4
Predictive power of symptoms for the diagnosis of dizziness

Percentage
of Study
Population Positive
with Odds Likelihood
Diagnosis Diagnosis Grouping of Symptoms with the Highest Positive Predictive Value Ratio Ratio
Benign positional vertigo 24.3 No dizziness between attacks, positional 11.25 5.659
Migraine 17.4 Photophobia, worse in moments of stress, associated headache 87.75 70.4
Meniere 14.2 Hearing change during attack, aural fullness 8.645 4.75
Vestibular neuritis 8.1 Dizziness in attacks, nausea, attacks <20 min 2.565 1.804
reservados.
Central 7.1 Constant dizziness, history of depression, neurologic comorbidity 26.607 22.72
Anxiety 5.3 Worse in moments stress, breathing quickly while dizzy, numbness in face/ 4.111 3.667
extremities
Cardiac 5.3 Confusion, history of fall, history of loss of consciousness 7.364 6.303
Overview of Dizziness in Practice

Postural 3.5 Weakness/clumsiness, age >60 y, difficulty hearing 5.084 3.808
Bilateral vestibular loss 3.3 Irregular heartbeat, difficulty walking in the dark, frequency (once a month) 18.36 15.467
Unilateral vestibular loss 3.1 Difficulty hearing. cardiac comorbidity, family history of deafness 5.729 4.637
Cervical 1.9 Weakness/clumsiness, slurred speech, facial weakness 19.020 15.016
Other 5.9 NA NA NA
Abbreviation: NA, not available.

Reprinted with permission from authors From Goebel JA. Evaluation of the dizzy patient: History and physical examination. Research in Vestibular Science.
2011;10:S107-S122, with permission.
847
848 Weinreich et al
Table 5
List of specialists and conditions
Specialty Diseases, Conditions, or Testing

Cardiology Arrhythmias, postural orthostatic tachycardia syndrome
Memory clinic Neurocognitive assessment
Neurology Central examination findings, abnormal oculomotor
findings, vestibular migraine
Physical therapy Posturography, vestibular rehabilitation
Psychiatry Persistent postural-perceptual dizziness, anxiety disorders
Traumatic brain injury clinic Comprehensive evaluation
Thus, having a team member who can help manage patients’ anxiety may further help
in the patients’ recovery and compensation. A team may include otolaryngology/neuro-
otology, neurology, neuro-ophthalmology, audiology, physical therapy, psychiatry/psy-
chology, and social work. Formats can vary from true multidisciplinary clinics, to inclu-
sion of group treatment, to a regularly scheduled vestibular conference.21,22 In the
experience of the Ottawa Hospital multidisciplinary clinic, the clinic screened patients,
improved diagnostic accuracy, ensured appropriate diagnostic testing, and facilitated
effective care plans for patients with dizziness in both acute and chronic settings.22 In-
clusion of interdisciplinary clinics with group treatment furthermore improved patient
mood, physical and mental health, functionality, and satisfaction.23
A specific note regarding falls: one of the many realities of dizzy patients is that they
may have a true vestibular loss. The cause of the loss may never be known; however,
improving balance and preventing a fall may be the only option. In the United States,
falls made up the greatest percentage of injuries in 2019, with an estimated 2.6 million
nonfatal falls and 21,700 fatal falls.24
Vestibular patients should be screened for falls. The American Geriatrics Society rec-
ommends that all patients older than 65 years with a history of falls, balance, or gait dis-
order should undergo multifactorial falls risk evaluation.25 Screening tools listed here
measure the effect of imbalance and falls risk on functional status and patient quality of life:
Falls Efficacy Scale26
The Activities Balance Confidence Scale27
Lawton Instrumental Activities of Daily Living Scale28
The development of a falls clinic can specifically target these at-risk patients. A team
can include otolaryngologists, ophthalmologists, physical medicine and rehabilitation,
geriatricians, neurologists, orthopedists, cardiologists, physiatrists, psychiatrists, and
physical and occupational therapists.
In addition to a standardized physical examination, a falls examination should
include evaluation of orthostatic vital signs, strength, sensory and reflex testing, and
inclusion of the following tests:
Mini-BEST (Balance Evaluations Systems Test)29
SARA (Scale for the Assessment and Rating of Ataxia)30
MOCA (Montreal Cognitive Assessment)31
QUALITY INDICTORS
Given the need for patient-reported outcomes, every clinician should strive to adhere
to and track quality indicators. Published in 2017, a multidisciplinary work group pro-
vided recommendations regarding the following32:
reservados.
Quality of life for patients with neuro-otology disorders

Vestibular rehabilitation for unilateral or bilateral vestibular hypofunction
Dix-Hallpike maneuver performed for patients with BPPV
Canalith repositioning procedure performed for patients with posterior canal
BPPV
Standard BPPV management
A validated quality improvement tool can provide objective data for patients and
provide data for both clinician and patient about how the patient is responding to treat-
ment. Several published tools exist.32
SUMMARY
In summary, dizzy patients can be challenging, but having a plan for how to screen and
schedule, how to gather data, and how to develop a workflow for testing can improve
efficiency. Development of a team approach can alleviate some of the burden and
helps to provide better care. The bottom line is to be thoughtful about these patients.
The reality is that if clinicians provide efficient and high-quality care, the successful
management of dizzy patients can be rewarding.
CLINICS CARE POINTS
Only 50% of patients presenting to an otolaryngology clinic have a neuro-otologic

condition.
Screening tools and questionnaires should be used to efficiently categorize patients based
on evidence-based symptoms.
Vestibular testing is not diagnostic.
Create a multidisciplinary clinic.
Screen high-risk patients for falls.
DISCLOSURE
The authors have nothing to disclose. H.W. Weinreich is funded by the University of
Illinois at Chicago (UIC)’s Building Interdisciplinary Research Careers in Women’s
Health (BIRCWH) grant K12HD101373 from the National Institutes of Health (NIH) Of-
fice of Research on Women’s Health. Y. Agrawal is funded by the National Institute on
Aging R01 AG057667.
REFERENCES
1. Edlow JA. Diagnostic algorithm for patients presenting with acute dizziness: The
ATTEST method. In: Micieli G, Cavallini A, Ricci S, et al, editors. Decision algo-
rithms for emergency neurology. Springer-Cham; 2021. https://doi.org/10.1007/
978-3-030-51276-7_9.
2. Bosner S, Schwarm S, Grevenrath P, et al. Prevalence, aetiologies and prognosis
of the symptom dizziness in primary care - a systematic review. BMC Fam Pract
2018;19(1):33.
3. Centers for Disease Control and Prevention. Emergency department visits. 2021.
Available at: https://www.cdc.gov/nchs/fastats/emergency-department.htm. Ac-
cessed February 26, 2021.
reservados.
850 Weinreich et al
4. Jayarajan V, Rajenderkumar D. A survey of dizziness management in general

practice. J Laryngol Otol 2003;117(8):599–604.
5. Arya AK, Nunez DA. What proportion of patients referred to an otolaryngology
vertigo clinic have an otological cause for their symptoms? J Laryngol Otol
2008;122(2):145–9.
6. Friedland DR, Tarima S, Erbe C, et al. Development of a statistical model for the
prediction of common vestibular diagnoses. JAMA Otolaryngol Head Neck Surg
2016;142(4):351–6.
7. Saber Tehrani AS, Kattah JC, Kerber KA, et al. Diagnosing stroke in acute dizzi-
ness and vertigo: Pitfalls and pearls. Stroke 2018;49(3):788–95.
8. Kattah JC, Talkad AV, Wang DZ, et al. HINTS to diagnose stroke in the acute
vestibular syndrome: Three-step bedside oculomotor examination more sensitive
than early MRI diffusion-weighted imaging. Stroke 2009;40(11):3504–10.
9. Saber Tehrani AS, Coughlan D, Hsieh YH, et al. Rising annual costs of dizziness
presentations to U.S. emergency departments. Acad Emerg Med 2013;20(7):
689–96.
10. IBM Micromedex. Meclizine hydrochloride. Available at: www-micromedexsolutions-
com. Accessed February 23, 2021.
11. Zhao JG, Piccirillo JF, Spitznagel EL, et al. Predictive capability of historical data
for diagnosis of dizziness. Otol Neurotol 2011;32(2):284–90.
12. Britt CJ, Ward BK, Owusu Y, et al. Assessment of a statistical algorithm for the
prediction of benign paroxysmal positional vertigo. JAMA Otolaryngol Head
Neck Surg 2018;144(10):883–6.
13. Kentala E, Rauch SD. A practical assessment algorithm for diagnosis of dizzi-
ness. Otolaryngol Head Neck Surg 2003;128(1):54–9.
14. McCaslin DL. 20Q: Using artificial intelligence to triage and manage patients with
dizziness - the mayo clinic experience. 2020. Available at: https://www.
audiologyonline.com/articles/20q-using-artificial-intelligence-to-26880. Ac-
cessed February 26, 2021.
15. Adams ME, Yueh B, Marmor S. Clinician use and payments by medical specialty
for audiometric and vestibular testing among US medicare beneficiaries. JAMA
Otolaryngol Head Neck Surg 2020;146(2):143–9.
16. Piker EG, Schulz K, Parham K, et al. Variation in the use of vestibular diagnostic
testing for patients presenting to otolaryngology clinics with dizziness. Otolar-
yngol Head Neck Surg 2016;155(1):42–7.
17. Goebel JA. Evaluation of the dizzy patient: History and physical examination. Res
Vestib Sci 2011;10:S107–22.
18. Committee on hearing and equilibrium guidelines for the diagnosis and evalua-
tion of therapy in meniere’s disease. american academy of otolaryngology-
head and neck foundation, inc. Otolaryngol Head Neck Surg 1995;113(3):181–5.
19. Lahmann C, Henningsen P, Brandt T, et al. Psychiatric comorbidity and psycho-
social impairment among patients with vertigo and dizziness. J Neurol Neurosurg
Psychiatry 2015;86(3):302–8.
20. MacDowell SG, Wellons R, Bissell A, et al. The impact of symptoms of anxiety and
depression on subjective and objective outcome measures in individuals with
vestibular disorders. J Vestib Res 2018;27(5–6):295–303.
21. Staibano P, Lelli D, Tse D. A retrospective analysis of two tertiary care dizziness
clinics: A multidisciplinary chronic dizziness clinic and an acute dizziness clinic.
J Otolaryngol Head Neck Surg 2019;48(1):11.
22. Bachmann K, Lavender V, Castiglione M. Development of a pediatric balance
center: A multidisciplinary approach. Semin Hear 2018;39(3):243–56.
reservados.
23. Naber CM, Water-Schmeder O, Bohrer PS, et al. Interdisciplinary treatment for
vestibular dysfunction: The effectiveness of mindfulness, cognitive-behavioral
techniques, and vestibular rehabilitation. Otolaryngol Head Neck Surg 2011;
145(1):117–24.
24. Centers for Disease Control and Prevention. Injury data 2019. Available at:
https://www.cdc.gov/injury/wisqars/index.html. Accessed April 6, 2021.
25. Guideline for the prevention of falls in older persons. american geriatrics society,
british geriatrics society, and american academy of orthopaedic surgeons panel
on falls prevention. J Am Geriatr Soc 2001;49(5):664–72.
26. Tinetti ME, Richman D, Powell L. Falls efficacy as a measure of fear of falling.
J Gerontol 1990;45(6):239.
27. Powell LE, Myers AM. The activities-specific balance confidence (ABC) scale.
J Gerontol A Biol Sci Med Sci 1995;50A(1):28.
28. Lawton MP, Brody EM. Assessment of older people: Self-maintaining and instru-
mental activities of daily living. Gerontologist 1969;9(3):179–86.
29. Franchignoni F, Horak F, Godi M, et al. Using psychometric techniques to improve
the balance evaluation systems test: The mini-BESTest. J Rehabil Med 2010;
42(4):323–31.
30. Schmitz-Hubsch T, du Montcel ST, Baliko L, et al. Scale for the assessment and
rating of ataxia: Development of a new clinical scale. Neurology 2006;66(11):
1717–20.
31. Nasreddine ZS, Phillips NA, Bedirian V, et al. The montreal cognitive assessment,
MoCA: A brief screening tool for mild cognitive impairment. J Am Geriatr Soc
2005;53(4):695–9.
32. Neurology Quality Measurement Work Group (authors). Universal Neurology
Quality Measurement Set. American Academy of Neurology Institute: American
Medical Association; 2019. p. 1–69.
33. Newman-Toker DE, Cannon LM, Stofferahn ME, et al. Imprecision in patient re-
ports of dizziness symptom quality: a cross-sectional study conducted in an
acute care setting. Mayo Clin Proc 2007;82:1329–40.
34. Lee H, Sohn SI, Cho YW, et al. Cerebellar infarction presenting isolated vertigo:
frequency and vascular topographical patterns. Neurology 2006;67:1178–83.
35. Neuro-otologic disorders. Continuum (Minneap Minn) 2012;18(5 Neuro-otology):
1016–40.
36. Häusler R, Levine RA. Auditory dysfunction in stroke. Acta Otolaryngol 2000;120:
689–703.
37. Chang TP, Wang Z, Winnick AA, et al. Sudden hearing loss with vertigo portends
greater stroke risk than sudden hearing loss or vertigo alone. J Stroke Cerebro-
vasc Dis 2018;27:472–8.
38. Newman-Toker DE, Kerber KA, Hsieh YH, Pula JH, Omron R, Saber Tehrani AS,
et al. HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo
and dizziness. Acad Emerg Med 2013;20:986–96.
39. Lempert T, Neuhauser H, Daroff RB. Vertigo as a symptom of migraine. Ann N Y
Acad Sci 2009;1164:242–51.
40. Hoshino T, Nagao T, Mizuno S, et al. Transient neurological attack before verte-
brobasilar stroke. J Neurol Sci 2013;325:39.
41. Tarnutzer AA, Berkowitz AL, Robinson KA, et al. Does my dizzy patient have a
stroke? A systematic review of bedside diagnosis in acute vestibular syndrome.
CMAJ 2011;183:E571–92.
reservados.
852 Weinreich et al
42. Kattah JC, Talkad AV, Wang DZ, et al. HINTS to diagnose stroke in the acute
vestibular syndrome: threestep bedside oculomotor examination more sensitive
than early MRI diffusion-weighted imaging. Stroke 2009;40:3504–10.
43. Gottesman RF, Sharma P, Robinson KA, et al. Clinical characteristics of symptom-
atic vertebral artery dissection: a systematic review. Neurologist 2012;18:245–54.
44. erber KA, Burke JF, Brown DL, et al. Does intracerebral haemorrhage mimic
benign dizziness presentations? A population based study. Emerg Med J
2012;29:43–6.
45. Hwang DY, Silva GS, Furie KL, Greer DM. Comparative sensitivity of computed
tomography vs. magnetic resonance imaging for detecting acute posterior fossa
infarct. J Emerg Med 2012;42:559–65.
46. Lawhn-Heath C, Buckle C, Christoforidis G, et al. Utility of head CT in the evalu-
ation of vertigo/dizziness in the emergency department. Emerg Radiol 2013;
20:45–9.
47. Ozono Y, Kitahara T, Fukushima M, et al. Differential diagnosis of vertigo and
dizziness in the emergency department. Acta Otolaryngol 2014;134:140–5.
48. Axer H, Grässel D, Brämer D, et al. Time course of diffusion imaging in acute
brainstem infarcts. J Magn Reson Imaging 2007;26:905–12.

reservados.

Overview of Dizziness in Practice

Uploaded by

Copyright:

Available Formats

Overview of Dizziness in Practice

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Overview of Dizziness in Practice

Uploaded by

Copyright:

Available Formats

Overview of Dizziness in

Annually, 3% to 4% of all patients who present to an emergency department (ED) have

Otolaryngol Clin N Am 54 (2021) 839–852

NATURE OF THE PROBLEM

Approximately 50% of dizzy patients evaluated in an otolaryngology clinic are true

Creating a High-Yield Patient Population

Pitfall Pearl Notes

(continued on next page)

Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de

Selectively Refer to Vestibular Testing

Testing Before Evaluation Testing After Evaluation

Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de

Test What Does It Test? Physiology Pathophysiology

(continued on next page)

Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de

Develop a Network of Collaborators and Specialists

Multidisciplinary Teams and Falls Clinic

Predictive power of symptoms for the diagnosis of dizziness

Overview of Dizziness in Practice

Abbreviation: NA, not available.

Specialty Diseases, Conditions, or Testing

 Quality of life for patients with neuro-otology disorders

CLINICS CARE POINTS

 Only 50% of patients presenting to an otolaryngology clinic have a neuro-otologic

4. Jayarajan V, Rajenderkumar D. A survey of dizziness management in general

Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de

You might also like

Quality of life for patients with neuro-otology disorders

Only 50% of patients presenting to an otolaryngology clinic have a neuro-otologic