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PATIENT HISTORY

Before performing any vestibular test, taking a thorough medical history and ascertaining the patient’s symptoms constitute the first steps in caring for a patient with a vestibular disorder. Sometimes the patient history alone may suggest a diagnosis.

Symptoms

Taking a patient history should include determining the patient’s symptoms, including balance, hearing, vision, somatosensation, and motor function. The first task for a neurotologist is to allow the patient to describe what he or she senses. The clinician may help the patient in choosing the correct terms to describe these complaints.

A. Vertigo and Dizziness

Even though these 2 terms are used interchangeably, there are some differences between them.

Vertigo can be described as an unreal sense of rotationary movement. It is a rotatory illusion. It should be distinguished from dizziness, which describes any kind of altered sense of orientation. A history of vertigo is of great value in identifying the presence of vestibular pathology but not in localizing its origin. Vertigo results from impaired tonic symmetry in the inputs of the vestibular nuclei. Therefore, a vestibular lesion can occur anywhere within the vestibular end-organs, the vestibular nuclei, the cerebellum, the pathways connecting these structures in the brainstem, and, rarely, within the cortex. Vertigo is mostly caused by peripheral lesions; however, 2 central lesions (vascular events of brainstem and cerebellum) also present with vertigo. On the contrary, even though dizziness can be a mark of a central lesion, it may arise from decompensated status of a peripheral lesion, vitamin B12 deficiency, folic acid deficiency, or hyperlipidemia. It is a symptom that the patient can tolerate, but then the patient tends to seek help with some delay. The clinician should determine whether the vertigo occurs in episodes or continuously. If it is episodic, it should be ascertained how often the episodes occur and how long they last. In peripheral causes, vertigo occurs in episodes with an abrupt onset. It disappears in varying time periods, from seconds to days, based on the underlying pathology. The origin of intensive, episodic vertigo that lasts up to a minute is more likely benign paroxysmal positional vertigo (BPPV) if it is provoked with particular positions. Another cause of brief but recurrent vertigo or dizziness, especially if precipitated by body straining, is perilymph fistula. Vertigo that lasts 2 to 20 minutes is consistent with a transient ischemic attack, which affects the posterior circulation if it is associated with visual deficits, ataxia, and localized neurologic findings. Meniere disease causes recurrent vertigo attacks that can last between 20 minutes and 12 to 24 hours. An isolated attack of vertigo (without hearing loss) that lasts more than 24 hours is suggestive of vestibular neuronitis. Duration of vertigo/dizziness in migraine-induced vertigo may range from seconds to several days with bilateral tinnitus but no hearing loss. Autonomic symptoms such as nausea, vomiting, and sweating are common presenting symptoms.

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