For those in the audience that aren’t medical people, the differential or differential diagnosis is a working list of things that MIGHT be happening given a set of certain history and assessment findings. Here before you are the list of things that MIGHT be going on with someone who has a sudden case of dizzies and what you’ll hear or see from the previous history or physical exam sections in those cases.
***Disclaimer: This article/website is not intended to diagnosis or treat any medical condition real or imagined. If you are experiencing a sudden case of dizziness, please seek out your nearest medical professional who can appropriately perform the testing required to determine YOUR differential diagnosis. Thank you. ***
Benign positional positional vertigo: The patient will describe a sudden, “brief episode of vertigo [spinning] and nystagmus [uncontrolled repetitive eye movements] which lasts… [about] 5 seconds.” This is fairly typical of the canalithisis. The cupulolithiasis can last a couple of minutes. There are likely to have been several distinct episodes of this.
Vestibular neuritis/labyrinthitis or acute idiopathic unilateral peripheral vestibulopathy: “… [A] spinning vertigo that persists for days and weeks and is [made worse] with head motion.” This one isn’t as episodic, although it can wax and wane in severity. About half the time the patient will have had a virus in the last couple of weeks, which they may describe as a cold, allergies or a stomach bug. They may also have nausea and/or vomiting, general tired feeling, be pale and sweaty. Sometimes they will veer off toward the effected side when they walk. When examining their eye balls you’ll see a unidirectional nystagmus that is typically horizontal with a rotational component as well. You’ll get a positive HIT test toward the involved side. The article also recommends caloric testing in these cases to confirm diagnosis and monitor recovery.
Cerebellar stroke: “…[An] abrupt onset of [spinning sensation] (within seconds) often accompanied by … headache [located at the back base of the skull]. Other associated sings may include [incoordination], facial numbness, Horner’s syndrome [droopy eyelid and unequal pupil sizes], hearing loss, [one sided weakness or numbness].” The HIT will be normal here. There may not be any nystagmus, hearing loss or incoordination.
Migrainous vertigo: This is a diagnosis of exclusion, meaning you have to rule out EVERYTHING else in the differential and have the following history. You’ll have a person who has a history of migraine who “has noticed a recent increase in headache frequency, and in the same period, developed vestibular episodes, with headache and vertigo not necessarily occurring together. Other migrainous features such as [light sensitivity], [noise sensitivity], and nausea are often present during the [dizzy spells.]” Many will have nystagmus or other signs associated with central dizziness (requiring imaging) and will report spontaneous or positional spinning lasting hours to days. rocking-This sensation can be described as a “…gentle ‘rocking-in-a-boat’ to a terrifying ‘merry-go-round…”
Bilateral vestibular failure: These folk have been on strong ototoxic drugs, usually having been in intensive care with multi-organ problems. If they were conscious while in intensive care, they’ll complain of episodic dizziness that last minutes to hours. If they can walk, they’ll have severe problems with balance while walking and double vision when they move their head. You’ll get a positive HIT on both sides and can confirm with caloric testing. The dizzy spells will reduce over a few days.
If the patient is also complaining of sudden deafness, there are a whole new slough of diagnosis that need to be considered. We’ll hit those up next time.
I’m currently in the midst of doing a literature review in preparation to write a case report. If you would like more background information on the case or information about the project, please click here. If you would like to see other article reviews related to this project, please click here.