CONTINUUM Lifelong Learning in Neurology

PURPOSE OF REVIEW: This article reviews a method of obtaining the medical history of patients presenting with dizziness, vertigo, and imbalance. By combining elements of the history with examination, the goal is to identify patterns and an effective differential diagnosis for this group of patients to help lead to an accurate diagnosis.

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Vestibular Testing

Hain, Timothy C. MD; Cherchi, Marcello MD, PhD, FAAN

doi : 10.1212/CON.0000000000000978

Issue: Volume 27(2), April 2021, p 330-347

PURPOSE OF REVIEW: Vestibular testing, both at the bedside and in the laboratory, is often critical in diagnosing patients with symptoms of vertigo, dizziness, unsteadiness, and oscillopsia. This article introduces readers to core concepts, as well as recent advances, in bedside and instrumented vestibular assessments.

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Episodic Positional Dizziness

Kerber, Kevin A. MD, MS

doi : 10.1212/CON.0000000000000909

Issue: Volume 27(2), April 2021, p 348-368

PURPOSE OF REVIEW: This article provides a summary of the evaluation and treatment of patients presenting with episodic positional dizziness.RECENT FINDINGS: Positional components are nearly ubiquitous among diagnoses of dizziness, so it can be challenging to classify patients with episodic positional dizziness simply based on the history of present illness. Overreliance on the presence of a report of positional components has likely resulted in misapplication or misinterpretation of positional testing and negative experiences with maneuvers to treat positional dizziness. The prototypical episodic positional dizziness disorder is benign paroxysmal positional vertigo (BPPV). BPPV is caused by free-floating particles in a semicircular canal that move in response to gravity. The diagnosis is made by identifying the characteristic patterns of nystagmus on the Dix-Hallpike test. Particle repositioning for BPPV is supported by randomized controlled trials, meta-analyses, and practice guidelines. Other disorders that can present with episodic positional dizziness are migraine dizziness, central lesions, and light cupula syndrome.

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Episodic Spontaneous Dizziness

Eggers, Scott D. Z. MD

doi : 10.1212/CON.0000000000000931

Issue: Volume 27(2), April 2021, p 369-401

PURPOSE OF REVIEW: Conditions causing recurrent spontaneous episodes of dizziness or vertigo span several medical specialties, making it challenging for clinicians to gain confidence in evaluating and managing the spectrum of episodic vestibular disorders. Patients are often asymptomatic and have normal examinations at the time of evaluation. Thus, diagnosis depends heavily on eliciting key features from the history. Overreliance on symptom quality descriptions commonly leads to misdiagnosis. The goal of this article is to provide the reader with a straightforward approach to the diagnosis and management of conditions that cause episodic spontaneous dizziness.

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Acute Vestibular Syndrome

Steenerson, Kristen K. MD

doi : 10.1212/CON.0000000000000958

Issue: Volume 27(2), April 2021, p 402-419

RECENT FINDINGS: Acute vestibular syndrome is defined as sudden-onset, continuous vertigo lasting longer than 24 hours with associated nausea and vomiting, all of which are worsened with head movement. Acute vestibular syndrome is provoked by a variety of central and peripheral causes, the most common of which are vestibular neuritis and acute stroke (posterior circulation). A clinical approach focusing on timing, associated history, and ocular motor findings can improve diagnostic accuracy and is more sensitive and specific than early neuroimaging. Because of the shared neurovascular supply, both peripheral and central vestibular disorders can manifest overlapping signs previously considered solely peripheral or central, including vertical skew, nystagmus, abnormal vestibular ocular reflex, hearing loss, and gait instability. Although acute vestibular syndrome is typically benign, stroke should be considered in every person with acute vestibular syndrome because it can act as a harbinger of stroke or impending cerebellar herniation. Treatment is focused on physical therapy because the evidence is minimal for the long-term use of medication.

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Chronic Dizziness

Cha, Yoon-Hee MD, FAAN

doi : 10.1212/CON.0000000000000932

Issue: Volume 27(2), April 2021, p 420-446

PURPOSE OF REVIEW: Determining the etiology of disorders that manifest with chronic dizziness can seem a daunting task, but extracting some basic elements of the patient's history can reduce the differential diagnosis significantly. This includes determining initial triggers, timing of symptoms, associated features, and exacerbating factors. This article covers distinct causes of chronic dizziness including persistent postural perceptual dizziness, mal de debarquement syndrome, motion sickness and visually induced motion sickness, bilateral vestibulopathy, and persistent dizziness after mild concussion.

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Vertigo Related to Central Nervous System Disorders

Saha, Kamala MD

doi : 10.1212/CON.0000000000000933

Issue: Volume 27(2), April 2021, p 447-467

PURPOSE OF REVIEW: This article provides an overview of the numerous causes of vertigo and dizziness that are due to central nervous system (CNS) pathology and guides clinicians in formulating a differential diagnosis and treating patients with CNS causes of vertigo.

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Selected Otologic Disorders Causing Dizziness

Ishiyama, Gail MD

doi : 10.1212/CON.0000000000000977

Issue: Volume 27(2), April 2021, p 468-490

PURPOSE OF REVIEW: This article details updated clinical presentations and current treatment paradigms of the common otologic disorders that may present to the neurologist for vertigo, including Meniere disease, superior semicircular canal dehiscence syndrome, perilymphatic fistula, barotrauma, cholesteatoma, Ramsay Hunt syndrome, enlarged vestibular aqueduct syndrome, and autoimmune inner ear disease including Cogan syndrome.

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Tinnitus, Hyperacusis, Otalgia, and Hearing Loss

Fife, Terry D. MD, FAAN, FANS; Tourkevich, Roksolyana MD

doi : 10.1212/CON.0000000000000961

Issue: Volume 27(2), April 2021, p 491-525

PURPOSE OF REVIEW: This article reviews the causes of tinnitus, hyperacusis, and otalgia, as well as hearing loss relevant for clinicians in the field of neurology.

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