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February 2, 1994, Vol 271, No. 5 >
ARTICLE | February 2, 1994

Does This Dizzy Patient Have a Serious Form of Vertigo? FREE

David A. Froehling, MD; Marc D. Silverstein, MD; David N. Mohr, MD; Charles W. Beatty, MD
[+] Author Affiliations

Reprint requests to Mayo Clinic, 200 First St SW, Rochester, MN 55905 (Dr Silverstein).


JAMA. 1994;271(5):385-388. doi:10.1001/jama.1994.03510290067039
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References

CLINICAL SCENARIOS: COMMON CAUSES OF VERTIGO 

Patient 1  A 52-year-old woman was admitted to the hospital because of nausea, a constant spinning sensation, and vomiting of 24 hours' duration. Any movement of her head made these symptoms worse. On examination, she had bilateral horizontal spontaneous nystagmus. Two days later, after symptomatic improvement, she was dismissed. At follow-up 2 weeks later, her symptoms and nystagmus had completely resolved.

Patient 2  A 70-year-old woman had a 4-month history of an intermittent whirling sensation when turning her head and especially when rolling over in bed. On examination, a left-side-down head-hanging maneuver elicited rotatory nystagmus, with the fast component to the left ear (Figure). There was a latency of about 3 seconds before the onset of nystagmus, which lasted approximately 10 seconds.

WHY EVALUATE VERTIGO?  "Vertigo" is defined in Webster's dictionary2 as a disturbance "in which the external world seems to revolve around

REFERENCES

1 +
Mohr DN.  The syndrome of paroxysmal positional vertigo: a review. West J Med . 1986;;145:645-650.
2 +
Webster's Third New International Dictionary of the English Language, Unabridged . Springfield, Mass: Merriam-Webster Inc; 1986;:664, 2546.
3 +
Adams RD, Victor M.  Deafness, dizziness, and disorders of equilibrium.  In: Principles of Neurology . 3rd ed. New York, NY: McGraw-Hill Book Co; 1985;:216-218.
4 +
Kroenke K, Mangelsdorff AD.  Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome. Am J Med . 1989;;86:262-266.
5 +
Woodwell DA.  Office visits to internists, 1989. Advance Data . 1992;;209:1-10.
6 +
Herr RD, Zun L, Mathews JJ.  A directed approach to the dizzy patient. Ann Emerg Med . 1989;; 18:664-672.
7 +
Kroenke K, Lucas CA, Rosenberg ML, et al.  Causes of persistent dizziness: a prospective study of 100 patients in ambulatory care. Ann Intern Med . 1992;;117:898-904.
8 +
Drachman DA, Hart CW.  An approach to the dizzy patient. Neurology . 1972;;22:323-334.
9 +
Nedzelski JM, Barber HO, McIlmoyl L.  Diagnoses in a dizziness unit. J Otolaryngol . 1986;;15: 101-104.
10 +
Frederick MW.  Central vertigo. Otolaryngol Clin North Am . 1973;;6:267-285.
11 +
Kelly JP.  Vestibular system.  In: Kandel ER, Schwartz JH, eds. Principles of Neural Science . 2nd ed. New York, NY: Elsevier Science Publishing Co; 1985;:591-595.
12 +
Lehrer JF, Poole DC.  Diagnosis and management of vertigo. Compr Ther . (September) 1987;;13: 31-40.
13 +
Rowland LP.  Clinical syndromes of the brain stem.  In: Kandel ER, Schwartz JH, eds. Principles of Neural Science . 2nd ed. New York, NY: Elsevier Science Publishing Co; 1985;:599.
14 +
Mayo Clinic Dept of Neurology. Clinical Examinations in Neurology . 5th ed. Philadelphia, Pa: WB Saunders Co; 1981;:63-95.
15 +
Mylén CO.  Positional nystagmus: a review and future prospects. J Laryngol Otol . 1950;;64:295-318.
16 +
Plum F, Posner JB. The Diagnosis of Stupor and Coma . 3rd ed. Philadelphia, Pa: FA Davis Co; 1980;:58.
17 +
Olsson JE, Atkins JS.  Vestibular disorders. Otolaryngol Clin North Am . 1987;;20:83-111.
18 +
Barber HO.  Positional vertigo and nystagmus. Otolaryngol Clin North Am . 1973;;6:169-187.
19 +
Magarian GJ.  Hyperventilation syndromes: infrequently recognized common expressions of anxiety and stress. Medicine (Baltimore) . 1982;;61:219-236.
20 +
Fisher CM.  Vertigo in cerebrovascular disease. Arch Otolaryngol . 1967;;85:529-534.
21 +
Thomas JE, Cody DTR.  Neurologic perspectives of otosclerosis. Mayo Clin Proc . 1981;;56:17-21.
22 +
Pulec JL.  Meniere's disease: etiology, natural history, and results of treatment. Otolaryngol Clin North Am . 1973;;6:25-39.
23 +
Harner SG, Laws ER Jr.  Diagnosis of acoustic neurinoma. Neurosurgery . 1981;;9:373-379.
24 +
Dix MR, Hallpike CS.  The pathology, symptomatology, and diagnosis of certain common disorders of the vestibular system. Proc R Soc Med . 1952;;45:341-354.
25 +
Leliever WC, Barber HO.  Recurrent vestibulopathy. Laryngoscope . 1981;;91:1-6.
26 +
Slater R.  Benign recurrent vertigo. J Neurol Neurosurg Psychiatry . 1979;;42:363-367.
27 +
Alford BR.  Meniere's disease: criteria for diagnosis and evaluation of therapy for reporting (report of Subcommittee on Equilibrium and Its Measurement). Trans Am Acad Ophthalmol Otolaryngol . 1972;;76:1462-1464.
28 +
Harbert F.  Benign paroxysmal positional nystagmus. Arch Ophthalmol . 1970;;84:298-302.
29 +
Schuknecht HF.  Cupulolithiasis. Arch Otolaryngol . 1969;;90:765-778.
30 +
Silvoniemi P.  Vestibular neuronitis: an otoneurological evaluation. Acta Otolaryngol Suppl (Stockh) . 1988;;453:1-72.
31 +
Jackson GG, Arcieri G.  Ototoxicity of gentamicin in man: a survey and controlled analysis of clinical experience in the United States. J Infect Dis 1971;;124( (suppl) ):S130-S137.
32 +
Vernick DM, Branch WT Jr.  The painful or discharging ear.  In: Branch WT Jr, ed. Office Practice of Medicine . 2nd ed. Philadelphia, Pa: WB Saunders Co; 1987;:291-293.
33 +
Adams RD, Victor M.  Viral infections of the nervous system.  In: Principles of Neurology . 3rd ed. New York, NY: McGraw-Hill Book Co; 1985;: 552-553.
34 +
Nylen CO.  The oto-neurological diagnosis of tumours of the brain. Acta Otolaryngol . 1939;;33 ( (suppl) ):5-151.
35 +
Lachman J, Stahle J.  Vestibular neuritis: a clinical and electronystagmographic study. Neurology . 1967;;17:376-380.
36 +
Aantaa E, Virolainen E.  Vestibular neuronitis: a follow-up study. Acta Otorhinolaryngol Belg . 1979;; 33:401-404.
37 +
Baloh RW, Sakala SM, Honrubia V.  Benign paroxysmal positional nystagmus. Am J Otolaryngol . 1979;;1:1-6.
38 +
Katsarkas A, Kirkham TH.  Paroxysmal positional vertigo: a study of 255 cases. J Otolaryngol . 1978;;7:320-330.
39 +
Baloh RW, Honrubia V, Jacobson K.  Benign positional vertigo: clinical and oculographic features in 240 cases. Neurology . 1987;;37:371-378.
40 +
Froehling DA, Silverstein MD, Mohr DN, Beatty CW, Offord KP, Ballard DJ.  Benign positional vertigo: incidence and prognosis in a population-based study in Olmsted County, Minnesota. Mayo Clin Proc . 1991;;66:596-601.
41 +
Watson P, Barber HO, Deck J, Terbrugge K.  Positional vertigo and nystagmus of central origin. Can J Neurol Sci . 1981;;8:133-137.
42 +
Berkowitz BW.  Matutinal vertigo: clinical characteristics and possible management. Arch Neurol . 1985;;42:874-877.

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1 +
Mohr DN.  The syndrome of paroxysmal positional vertigo: a review. West J Med . 1986;;145:645-650.
2 +
Webster's Third New International Dictionary of the English Language, Unabridged . Springfield, Mass: Merriam-Webster Inc; 1986;:664, 2546.
3 +
Adams RD, Victor M.  Deafness, dizziness, and disorders of equilibrium.  In: Principles of Neurology . 3rd ed. New York, NY: McGraw-Hill Book Co; 1985;:216-218.
4 +
Kroenke K, Mangelsdorff AD.  Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome. Am J Med . 1989;;86:262-266.
5 +
Woodwell DA.  Office visits to internists, 1989. Advance Data . 1992;;209:1-10.
6 +
Herr RD, Zun L, Mathews JJ.  A directed approach to the dizzy patient. Ann Emerg Med . 1989;; 18:664-672.
7 +
Kroenke K, Lucas CA, Rosenberg ML, et al.  Causes of persistent dizziness: a prospective study of 100 patients in ambulatory care. Ann Intern Med . 1992;;117:898-904.
8 +
Drachman DA, Hart CW.  An approach to the dizzy patient. Neurology . 1972;;22:323-334.
9 +
Nedzelski JM, Barber HO, McIlmoyl L.  Diagnoses in a dizziness unit. J Otolaryngol . 1986;;15: 101-104.
10 +
Frederick MW.  Central vertigo. Otolaryngol Clin North Am . 1973;;6:267-285.
11 +
Kelly JP.  Vestibular system.  In: Kandel ER, Schwartz JH, eds. Principles of Neural Science . 2nd ed. New York, NY: Elsevier Science Publishing Co; 1985;:591-595.
12 +
Lehrer JF, Poole DC.  Diagnosis and management of vertigo. Compr Ther . (September) 1987;;13: 31-40.
13 +
Rowland LP.  Clinical syndromes of the brain stem.  In: Kandel ER, Schwartz JH, eds. Principles of Neural Science . 2nd ed. New York, NY: Elsevier Science Publishing Co; 1985;:599.
14 +
Mayo Clinic Dept of Neurology. Clinical Examinations in Neurology . 5th ed. Philadelphia, Pa: WB Saunders Co; 1981;:63-95.
15 +
Mylén CO.  Positional nystagmus: a review and future prospects. J Laryngol Otol . 1950;;64:295-318.
16 +
Plum F, Posner JB. The Diagnosis of Stupor and Coma . 3rd ed. Philadelphia, Pa: FA Davis Co; 1980;:58.
17 +
Olsson JE, Atkins JS.  Vestibular disorders. Otolaryngol Clin North Am . 1987;;20:83-111.
18 +
Barber HO.  Positional vertigo and nystagmus. Otolaryngol Clin North Am . 1973;;6:169-187.
19 +
Magarian GJ.  Hyperventilation syndromes: infrequently recognized common expressions of anxiety and stress. Medicine (Baltimore) . 1982;;61:219-236.
20 +
Fisher CM.  Vertigo in cerebrovascular disease. Arch Otolaryngol . 1967;;85:529-534.
21 +
Thomas JE, Cody DTR.  Neurologic perspectives of otosclerosis. Mayo Clin Proc . 1981;;56:17-21.
22 +
Pulec JL.  Meniere's disease: etiology, natural history, and results of treatment. Otolaryngol Clin North Am . 1973;;6:25-39.
23 +
Harner SG, Laws ER Jr.  Diagnosis of acoustic neurinoma. Neurosurgery . 1981;;9:373-379.
24 +
Dix MR, Hallpike CS.  The pathology, symptomatology, and diagnosis of certain common disorders of the vestibular system. Proc R Soc Med . 1952;;45:341-354.
25 +
Leliever WC, Barber HO.  Recurrent vestibulopathy. Laryngoscope . 1981;;91:1-6.
26 +
Slater R.  Benign recurrent vertigo. J Neurol Neurosurg Psychiatry . 1979;;42:363-367.
27 +
Alford BR.  Meniere's disease: criteria for diagnosis and evaluation of therapy for reporting (report of Subcommittee on Equilibrium and Its Measurement). Trans Am Acad Ophthalmol Otolaryngol . 1972;;76:1462-1464.
28 +
Harbert F.  Benign paroxysmal positional nystagmus. Arch Ophthalmol . 1970;;84:298-302.
29 +
Schuknecht HF.  Cupulolithiasis. Arch Otolaryngol . 1969;;90:765-778.
30 +
Silvoniemi P.  Vestibular neuronitis: an otoneurological evaluation. Acta Otolaryngol Suppl (Stockh) . 1988;;453:1-72.
31 +
Jackson GG, Arcieri G.  Ototoxicity of gentamicin in man: a survey and controlled analysis of clinical experience in the United States. J Infect Dis 1971;;124( (suppl) ):S130-S137.
32 +
Vernick DM, Branch WT Jr.  The painful or discharging ear.  In: Branch WT Jr, ed. Office Practice of Medicine . 2nd ed. Philadelphia, Pa: WB Saunders Co; 1987;:291-293.
33 +
Adams RD, Victor M.  Viral infections of the nervous system.  In: Principles of Neurology . 3rd ed. New York, NY: McGraw-Hill Book Co; 1985;: 552-553.
34 +
Nylen CO.  The oto-neurological diagnosis of tumours of the brain. Acta Otolaryngol . 1939;;33 ( (suppl) ):5-151.
35 +
Lachman J, Stahle J.  Vestibular neuritis: a clinical and electronystagmographic study. Neurology . 1967;;17:376-380.
36 +
Aantaa E, Virolainen E.  Vestibular neuronitis: a follow-up study. Acta Otorhinolaryngol Belg . 1979;; 33:401-404.
37 +
Baloh RW, Sakala SM, Honrubia V.  Benign paroxysmal positional nystagmus. Am J Otolaryngol . 1979;;1:1-6.
38 +
Katsarkas A, Kirkham TH.  Paroxysmal positional vertigo: a study of 255 cases. J Otolaryngol . 1978;;7:320-330.
39 +
Baloh RW, Honrubia V, Jacobson K.  Benign positional vertigo: clinical and oculographic features in 240 cases. Neurology . 1987;;37:371-378.
40 +
Froehling DA, Silverstein MD, Mohr DN, Beatty CW, Offord KP, Ballard DJ.  Benign positional vertigo: incidence and prognosis in a population-based study in Olmsted County, Minnesota. Mayo Clin Proc . 1991;;66:596-601.
41 +
Watson P, Barber HO, Deck J, Terbrugge K.  Positional vertigo and nystagmus of central origin. Can J Neurol Sci . 1981;;8:133-137.
42 +
Berkowitz BW.  Matutinal vertigo: clinical characteristics and possible management. Arch Neurol . 1985;;42:874-877.

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