Kenneth E. Watford, DNP, APRN-C

Journal for Nurse Practitioners. 2013;9(10):712-713.

Introduction

Dizziness ranks as one of the most common medical complaints treated in primary care and is typically a dreaded complaint for the nurse practitioner (NP) because of the perceived complexities in making an accurate diagnosis. Dizziness accounts for about 5% of all primary care office visits in the United States.^[1] The economic impact of misdiagnosis can be significant as a result of unnecessary diagnostic testing and hospital admissions. The NP must understand the underlying causes of dizziness in order to make an accurate diagnosis. This article discusses a technique that can be easily used to simplify the diagnosis of dizziness.

Background

Dizziness is a broad term used to describe how we feel when our sense of balance is impaired. It can be difficult to diagnose because it is a subjective complaint that cannot always be easily measured. The symptom might be described by a patient as vertigo, disequilibrium, wooziness, or lightheadedness.

It is helpful to understand the components of our balance system. This complex system comprises the inner ear, vision, and somatosenses. A deficit in any of these systems can result in disequilibrium.

Diagnosis

The NP can obtain a detailed history of the patient’s symptoms within 5 minutes with direct questions. The patient should be asked to precisely describe the dizziness symptom. Is there true vertigo, disequilibrium, or lightheadedness? When was the first onset? What is the typical duration and frequency of each episode? Are there any triggers? Is there an associated headache, photophobia, phonophobia, or visual aura? Is there any hearing loss, tinnitus, ear fullness, or hearing fluctuations? Are there any vision problems or peripheral neuropathy?

The diagnosis can then be placed in 1 of the following 6 categories. The mnemonic HeLP a BIT can be used to easily remember them (Table).

Headache-related Dizziness

Vestibular migraine is a common cause of vertigo and may affect up to 1% of the general population.^[2] This condition is often misdiagnosed as Meniere disease. Patients with vestibular migraine might describe their dizziness as true vertigo, a rocking sensation, unsteadiness, or a sensation of walking on foam. The dizziness might be constant or intermittent. There may be an associated headache. Photophobia, phonophobia, or a visual aura may be associated. However, it is important to understand that vestibular migraine might occur without a headache.

Lightheadedness

This category is generally not related to any vestibular etiology. This type of dizziness is usually associated with cardiovascular problems, metabolic problems, orthostatic hypotension, or drug side-effects.

Positional Vertigo

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo and perhaps the easiest to diagnose. BPPV is caused by calcium carbonate crystals, or otoliths, that have moved from the vestibule of the inner ear into one or more of the semicircular canals. Although the exact etiology of BPPV is unknown, it is commonly considered to be a part of the natural aging process and accounts for 50% of vertigo in older adults.^[3]

Patients with BPPV usually describe an intense, sudden onset of true vertigo, lasting continuously for no more than 1–2 minutes. It will be triggered only by certain changes of head position, such as rolling over in bed. When BPPV is active, it can be easily diagnosed by performing a Dix Hallpike test. Treatment via a canalith repositioning maneuver is indicated.

Brain Tumor

Patients with brain tumors, such as meningiomas or acoustic neuromas, might present with acute onset, persistent vertigo. There might be visible vertical nystagmus. Because these symptoms could be confused with other less serious causes, neuro-imaging is indicated on patients with dizziness that, despite appropriate work-up, remains undiagnosed.

Imbalance

Imbalance, or disequilibrium, can have various etiologies. Bilateral or unilateral vestibular weakness is caused by damage to one or more of the vestibular nerves. A unilateral vestibular weakness can sometimes be diagnosed in the office setting by performing a Fukuda stepping test, where the patient marches in place with outreached arms and eyes closed. Patients with vestibular weakness will rotate toward the affected ear.

A more precise diagnosis can be obtained with vestibular testing such as electronystagmography. Treatment usually consists of vestibular rehabilitation, in which the therapist develops exercises that are designed to improve balance by allowing the inner ears, eyes, arms, and legs to work together more effectively. Other causes of imbalance include chronic vision problems that cause double or blurry vision. Peripheral neuropathy, especially in the feet, can also cause imbalance.

True Vertigo

Common diagnoses for vertigo lasting continuously for more than 1–2 minutes consist of vestibular neuronitis and Meniere disease. The etiology of vestibular neuronitis is unknown and these patients describe a sudden onset of true vertigo that may last up to several days. Once the vertigo has resolved, the patient may experience disequilibrium for up to several weeks. If sudden, unilateral hearing loss is also experienced, the patient should be referred to an ear, nose, and throat (ENT) specialist immediately for treatment.

Meniere disease is a chronic inner ear condition of unknown etiology in which patients experience debilitating recurrent attacks of vertigo lasting at least 20 minutes, unilateral tinnitus, and progressive, unilateral, low-frequency, sensorineural hearing loss. Referral to ENT is indicated for treatment.

Summary

Patients with dizziness are often misdiagnosed by their primary care provider. This inaccuracy may lead to years of frustration for the provider and misery for the patient. By obtaining a detailed and directed history, and then understanding the underlying etiologies of dizziness, clinicians can more easily and accurately diagnose their dizzy patients using the HeLP a BIT technique.

References

1. Post R, Dickerson L. Dizziness: a diagnostic approach. Am Fam Physician. 2010;82(4):361–368.
2. Lempert T, Oelsen J, Furman J, et al. Vestibular migraine: diagnostic criteria. J Vestib Res. 2012;22:167–172.
3. Kovar M, Jepson T, Jones S. Diagnosing and treating benign paroxysmal positional vertigo. J Gerontolog Nurs. 2006;32(12):22–27.

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