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A Practical Assessment Algorithm for Diagnosis of Dizziness
Article in Otolaryngology Head and Neck Surgery · February 2003
DOI: 10.1067/mhn.2003.47 · Source: PubMed
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A practical assessment algorithm for diagnosis of dizziness
ERNA KENTALA,
MD,
and STEVEN D. RAUCH,
MD,
Boston, Massachusetts, and Helsinki, Finland
OBJECTIVE: We sought to test a 3-parameter model
for diagnosis of dizziness based on the type and
temporal characteristics of the dizziness and on
hearing status.
STUDY DESIGN AND SETTING: We conducted a prospective blinded study at a tertiary referral neurotology practice. Before examination, patients completed a questionnaire reporting type and timing of
dizziness symptoms and hearing status. Clinical diagnoses were compared with questionnaire results.
RESULTS: Fifty-seven patients completed the questionnaire. We were able to correctly classify 21
(60%) of the 35 subjects who had a common otogenic cause of vertigo by the diagnostic algorithm.
CONCLUSION: A simple classification of dizziness
by type, timing, and hearing status can be selfreported by patients using a brief questionnaire.
This classification scheme is as good as others of
much greater complexity.
SIGNIFICANCE: The simple classification scheme
reported here is based on history alone and facilitates triage of dizzy patients into diagnostic groups
for work-up and management. (Otolaryngol Head
Neck Surg 2003;128:54-9.)
D izziness is a common chief complaint and can
be a symptom of a multitude of diseases. According to the National Institutes of Health National
Institute of Deafness and Other Communication
Disorders (NIDCD), approximately 40% of all
Americans will seek medical attention for dizziness at some time in their lives. NIDCD also
From the Department of Otology and Laryngology, Harvard
Medical School, Boston (Drs Kentala and Rauch), Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston (Drs Kentala and Rauch), and the Department of Otology and Laryngology, Helsinki University
Hospital, Helsinki (Dr Kentala).
Presented at the Research Forum of the American Academy
of Otolaryngology–Head and Neck Surgery, Denver, CO,
September 9-12, 2001.
Reprint requests: Steven D. Rauch, MD, Massachusetts Eye
and Ear Infirmary, 243 Charles St, Boston, MA 02114;
e-mail, sdr@epl.meei.harvard.edu.
Copyright © 2003 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc.
0194-5998/2003/$30.00 ⫹ 0
doi:10.1067/mhn.2003.47
54
reports that falls account for 50% of all accidental
deaths in the elderly. Despite the obvious public
health significance of dizziness, patients typically
have great difficulty getting quality care for this
complaint. They have trouble articulating the nature of the symptoms, the primary care and specialist physicians they see often have very limited
knowledge of the vestibular system, there are no
simple and readily available laboratory studies to
make a dizzy diagnosis, and economic pressure on
physicians to spend less time with more patients
works against the patient with a complicated and
time-consuming dizziness problem. It is certainly
a universal perception among otolaryngologists
that dizzy patients represent one of the most frustrating and frustrated groups of patients. Here, we
present a very simple questionnaire to guide the
physician in the initial triage of dizzy patients.
This is by no means the first questionnaire developed for this purpose. However, we believe its
combination of simplicity and efficacy distinguishes it from other methods.
Traditionally, evaluation of a dizzy patient begins with a long and exhaustive interview, followed by a complex physical examination of both
the ears and nervous system. Several authors have
published their approach to evaluating a dizzy
patient.1-7 Each emphasizes the value of a careful
and thorough case history. Besides asking for
symptoms and examining signs related to vertigo,
the physician must take the case history of other
diseases, to exclude possible trauma, exposure to
toxic substances, and other factors.3 The most
important questions to be considered are the duration and occurrence of vertigo, the aggravation
of symptoms by head movement, and the auditory
or neurologic symptoms associated with it.1,7 The
usefulness of these questionnaires in clinical practice has not been tested (or published).
A few expert systems have been developed to
aid the diagnostic task with dizzy patients.8-10
These expert systems are computer algorithms that
use information on frequency and duration of vertigo attack, characteristics of vertigo (spinning,
floating), associated hearing loss, tinnitus, and
Otolaryngology–
Head and Neck Surgery
Volume 128 Number 1
neurologic symptoms. In one such system this
information is supplemented with results from
otoneurologic and audiometric testing.7 Expert
systems have both strong and weak points. They
can handle large amounts of information and even
uncertainty. However, at best, their diagnostic accuracy is around 65%, and input of all required
information can be a time-consuming task.11 The
key questions in differentiating otologic causes of
dizziness are duration of hearing loss and tinnitus,
frequency and duration of vertigo attacks, and
occurrence of head injury in relation to the onset
of symptoms.7 In questionnaire-based studies, neither questions concerning head positioning induced vertigo nor neurologic symptoms were
among the most important questions.7
During the past decade, we developed a simple
practical clinical assessment algorithm for dizzy
patients. The approach is based on 3 parameters:
the type of dizziness, the temporal characteristics
of the dizziness, and the hearing status. This algorithm has been used for teaching as well as applied
informally in the clinical setting for several years.
The present prospective blinded study was undertaken to test the validity of using this 3-parameter
model as the basis for a diagnostic classification
scheme.
MATERIALS AND METHODS
We hypothesized (1) that a simple dizziness
classification could enable us to focus on patients
with high likelihood of otogenic dizziness, (2) that
patients could self-classify, and (3) that combining
the dizziness classification with information about
the duration of symptoms and presence or absence
of hearing loss would provide correct diagnoses.
Clinically, we use a simple dizziness classification
similar to that described by Froehling et al6 that
categorizes dizziness into 4 “flavors”: near syncope, dysequilibrium, true vertigo, and psychogenic dizziness. Near syncope is the feeling of
impending loss of consciousness. It represents inadequate cerebral perfusion. Common causes include postural hypotension, valvular heart disease
or arrhythmia, and carotid stenosis. These patients
are triaged to the internist or cardiologist.
Dysequilibrium is a feeling of imbalance or
impending fall. It can be further subdivided into
gait dysequilibrium or global dysequilibrium. Pa-
KENTALA and RAUCH 55
tients whose feeling of imbalance occurs exclusively during ambulation usually have neuromuscular or musculoskeletal problems affecting
sensory or motor function of the legs. Examples
include diabetic peripheral neuropathy, spinal stenosis, or cerebellar dysfunction. Such patients are
referred to the neurologist. In contrast, global dysequilibrium is present all the time or is aggravated
by any movement of the head or body (not just
walking). These patients may have ear or neurologic disease and need an otologic work-up.
True vertigo is defined as “a false sense of
motion”: either you are moving or the world is
moving about you. Whirling vertigo is a “special
case” of vertigo just as a square is a special case of
rectangles. Although rotatory or whirling vertigo
is often caused by the inner ear, the ear can cause
other movement sensations and the central nervous system can cause rotatory sensations. Patients with true vertigo need an otologic work-up.
Psychogenic dizziness is a difficult issue. Most
often, patients describe a “spacey” or “disconnected” dizziness without any feeling of motion or loss
of balance. Dizzy patients are often anxious or
depressed or belligerent, and these feelings may so
dominate their behavioral style that the physician
cannot see past them to the balance disorder. Although a psychiatric evaluation is indicated, psychiatric disease does not protect one from vestibulopathy and the otolaryngologist is well advised to
continue the work-up.
Subjects
Fifty-seven patients (42 women and 15 men)
referred to one of the authors (S.D.R.) for evaluation of dizziness in a tertiary referral setting completed the questionnaire. The mean age of subjects
was 47 years (age range, 20 to 78 years).
Procedures
Because classification of the four “flavors” of
dizziness is so straightforward, we proposed to let
the patients do it themselves. A questionnaire was
designed for this purpose (Appendix 1). This questionnaire seemed to offer an acceptable level of
simplicity while minimizing ambiguity in the answers provided by the patients. A prospective
blinded methodology was used. Consecutive
newly referred dizzy patients were asked to com-
Otolaryngology–
Head and Neck Surgery
January 2003
56 KENTALA and RAUCH
Table 1. Diagnostic algorithm matrix
True vertigo
Hearing
loss
Episodic
Persistent
No
Yes
BPPV
Meniere’s disease
Vestibular neuritis
Labyrinthitis
Each cell of the 2 ⫻ 2 matrix represents a putative otogenic vertigo
diagnosis. Patients are assigned to positions in the matrix depending
on their self-report of vertigo and hearing loss on the questionnaire
(see text for details).
plete the dizziness questionnaire in which they
self-report the type and timing of symptoms based
on the brief definitions contained in the questionnaire text. The questionnaire focused first on true
vertigo, and patients with this symptom were
asked to characterize the duration of the symptom
as episodic (short, medium, or long) versus persistent. Then patients were queried about the other
flavors of dizziness and their respective duration.
The questionnaire purposely has no question regarding symptoms produced by head position; because many patients believe that any head motion
enhances their symptoms, asking about symptoms
induced by head positioning could be misleading.
Patient hearing status was assessed by a single
question of whether they had hearing loss. Questionnaires were completed before seeing the otologist. The otologist was blinded to the questionnaire results and used patient history, clinical
examination, and results of audiometric and otoneurologic tests for the diagnostic work-up. Subsequently, the otologist’s diagnosis for each patient was extracted from the medical record.
Diagnostic classifications by the otologist and by
analysis of the questionnaire were compared.
Data Analysis
Patients reporting true vertigo on their questionnaires were assigned presumptive diagnoses according to the diagnostic algorithm in Table 1,
based on their self-report of dizziness type, duration, and hearing loss status. The 4 diagnoses in
this diagnostic matrix (benign paroxysmal positional vertigo [BPPV], Meniere’s disease, vestibular neuritis, labyrinthitis) represent the 4 most
common causes of otogenic vertigo. Classification
into one of these 4 diagnostic groups was based
only on the presence or absence of hearing loss
and the duration of vertigo (episodic versus persistent). The accuracy of the diagnostic algorithm was
assessed by comparing these presumptive diagnoses
with the clinical diagnoses assigned by the otologist
in his medical record, based on the assumption that
an expert clinician with a nuanced history and discretionary access to any necessary clinical tests
would give the “correct” diagnosis. Patients reporting dysequilibrium alone (without true vertigo) were
analyzed separately to compare questionnaire results
with otologic clinical diagnoses.
RESULTS
A definite clinical diagnosis was made by the
otologist in 49 (86%) of 57 patients. The remaining 8 patients were given descriptive diagnoses or
reported to have a presentation “suggestive of” a
disease. According to the medical records, 35
(61.4%) of 57 subjects belonged to the four disease groups that could be classified by the diagnostic algorithm (BPPV, Meniere’s disease, labyrinthitis, vestibular neuritis). Of the remaining 22
subjects, 8 (14%) had migraine-associated dizziness, whereas the other 14 had a variety of other
peripheral, central, or undiagnosed abnormalities.
Each patient with true vertigo was assigned to a
particular cell of the diagnostic algorithm matrix
based on his or her self-report of vestibular symptoms and hearing loss. Patients with short-duration
episodic vertigo and no hearing loss were assigned
to the BPPV cell; intermediate-duration vertigo
with hearing loss was assigned to the Meniere’s
disease cell; persistent vertigo with hearing loss
was assigned to the labyrinthitis cell; and persistent vertigo without hearing loss was assigned to
the vestibular neuritis cell. Patients with intermediate-duration episodic vertigo and no hearing loss
and patients with dysequilibrium but no vertigo
were unclassifiable by the matrix. Table 2 contains
a tabulation of all 41 subjects classified by the
diagnostic algorithm matrix.
For the 35 patients with clinical diagnoses of
BPPV (n ⫽ 8), Meniere’s disease (n ⫽ 15), vestibular neuritis (n ⫽ 9), and labyrinthitis (n ⫽ 3),
21 (60%) were correctly classified/diagnosed by
the simple 2 ⫻ 2 matrix shown in Table 1. The
remaining 14 were either misclassified (i.e., they
had 1 of the 4 putative diagnoses but were assigned to the wrong cell of the matrix) or unclas-
Otolaryngology–
Head and Neck Surgery
Volume 128 Number 1
KENTALA and RAUCH 57
Table 2. Clinical diagnoses of subjects assigned to each cell of the diagnostic algorithm matrix
True vertigo
Hearing loss
No
Yes
Episodic
Persistent
BPPV (4)
Vertebrobasilar insufficiency (1)
Cervical vertigo (1)
Meniere’s disease (2)
Vestibular neuritis (1)
Total ⫽ 9
Meniere’s disease (11)
Migraine-associated dizziness (1)
BPPV (2)
Vestibular neuritis (1)
Labyrinthitis (1)
Mal de debarquement (1)
Episodic peripheral vertigo (1)
Genetic inner ear degeneration (1)
Total ⫽ 19
Vestibular neuritis (5)
Utricular dysfunction (1)
Migraine-associated dizziness (2)
BPPV (1)
Imbalance, not otogenic (1)
Total ⫽ 10
Labyrinthitis (1)
Closed head trauma (1)
Otosclerosis dizziness syndrome (1)
Total ⫽ 3
BPPV, Benign paroxysmal positional vertigo.
In each cell, the first line represents those subjects correctly classified with the diagnostic algorithm. n values given in parentheses.
sified (i.e., they did not fit in the matrix because of
reporting intermediate-duration vertigo without
hearing loss or dysequilibrium without true vertigo). Of 8 patients with BPPV, 4 (50%) were
correctly classified, 2 (25%) were erroneously
classified as having Meniere’s disease because
they had unrelated hearing loss, 1 (12.5%) had
vestibular neuritis, and 1 (12.5%) was unclassified, reporting hearing loss and fainting. Of 15
patients with Meniere’s disease, 11 (73.3%) were
correctly classified, 2 (13.3%) were misclassified
as BPPV because they were unaware of their hearing loss and erroneously reported it to be normal,
and 2 (13.3%) were unclassified, reporting spaciness and/or dysequilibrium without true vertigo.
Of 9 patients with vestibular neuritis, 5 (55.6%)
were correctly classified, 1 (11.1%) was misclassified as Meniere’s disease because of unrelated
hearing loss, 1 (11.1%) was misclassified as BPPV
because of incorrect report of varying vertigo intensity as episodes, and 2 (22.2%) were unclassified because of reporting vertigo as a moderateduration episode rather than persistent. Of 3
patients with labyrinthitis, 1 (33.3%) was correctly
classified, 1 (33.3%) was misclassified as Meniere’s disease because of reporting vertigo as
episodes rather than persistent, and 1 (33.3%) was
unclassified by having reported hearing loss and
dysequilibrium without true vertigo.
Migraine-associated dizziness (MAD) patients
formed a fifth large clinical diagnostic group (8 of
57, or 14% of all subjects). Five of the 8 migraineurs (62.5%) were not classified by our algorithm. Their flavor of dizziness was most often
dysequilibrium or moderate-duration episodes of
true vertigo, without hearing loss. Two MAD patients (25%) were erroneously classified as having
vestibular neuritis because their dizzy spells lasted
longer. One MAD patient (12.5%) was misclassified as having Meniere’s disease because of unrelated hearing loss in addition to vertigo episodes.
DISCUSSION
This study set out to test the hypotheses that (1)
a simple dizziness classification could enable the
physician to focus on patients with high likelihood
of otogenic dizziness, (2) that patients could selfclassify, and (3) that combining the dizziness classification with information about the duration of
symptoms and presence or absence of hearing loss
would give correct diagnoses. Of the 57 patients in
the study, 35 had 1 of the 4 most common otogenic causes of dizziness, BPPV, Meniere’s disease, vestibular neuritis, or labyrinthitis. The simple 2 ⫻ 2 diagnostic algorithm matrix used to
analyze questionnaire results correctly classified
60% (21 of 35) of these patients. This correct
Otolaryngology–
Head and Neck Surgery
January 2003
58 KENTALA and RAUCH
Table 3. Group assignment versus actual diagnosis
True vertigo
Hearing loss
No
Putative diagnosis
Total No. in cell
Correct assignment/correct diagnosis
Correct assignment/different diagnosis
Total correct assignments
Yes
Putative diagnosis
Total No. in cell
Correct assignment/correct diagnosis
Correct assignment/different diagnosis
Total correct assignments
Episodic
Persistent
BPPV
9 (100)
4 (44.4)
2 (22.2)
6 (66.7)
Vestibular neuritis
10 (100)
5 (50)
4 (40)
9 (90)
Meniere’s disease
19 (100)
11 (57.9)
0 (0)
11 (57.9)
Labyrinthitis
3 (100)
1 (33.3)
2 (66.7)
3 (100)
Some patients were correctly assigned to cells of the diagnostic algorithm matrix based on their report of hearing status and vertigo but did not
have the disorder putatively assigned to the cell. Values in parentheses indicate percentages
classification rate compares favorably with results
from otoneurologic expert systems.11
The diagnostic algorithm matrix is far from
perfect; nearly half of subjects were unclassified
or misclassified. This might be due to any of
several reasons. The matrix is simplistic; there are
certainly subjects who are assigned to cells of the
matrix but do not have 1 of the 4 putative diagnoses. For example, a patient with cervical vertigo
may have episodic vertigo and normal hearing that
results in assignment to the “BPPV cell” of the
matrix[em]correctly assigned to the “short-duration vertigo/no hearing loss” cell but without
BPPV. Table 3 tabulates such cases in our study
population and demonstrates a high degree of assignment precision (58% to 67%) for subjects with
episodic vertigo and a very high degree of precision (90% to 100%) for those with persistent vertigo even though diagnostic accuracy is lower (a
substantial proportion of these patients do not
have BPPV, Meniere’s disease, vestibular neuritis,
or labyrinthitis). The oversimplification of the algorithm matrix also leads to misclassifications by
excluding some patients who have 1 of the 4
common diagnoses but have symptoms that deviate from the most common pattern. For example,
there were some subjects with Meniere’s disease
who were unclassified because they experienced
their attacks as intense dysequilibrium rather than
true vertigo. The algorithm is not well suited to
patients with multiple dizziness diagnoses because
the matrix allows only one choice of diagnosis and
the questionnaire offers only a cross section of
symptoms; for example, a patient with vestibular
neuritis who later developed BPPV would have a
combination of dizziness symptoms likely to lead
to misclassification by the algorithm. Some other
misclassifications resulted from a discrepancy between symptom description in the questionnaire
and symptom description by the patients. For example, there were vestibular neuritis and labyrinthitis patients misclassified as having Meniere’s
disease because they reported persistent dizziness
of varying intensity as separate episodes. Finally,
there were misclassifications because of confounding symptoms. For example, a patient with
BPPV had unrelated hearing loss due to old acoustic trauma and was misclassified as having Meniere’s disease because of the co-occurrence of
hearing loss and episodic vertigo.
The results presented herein are based on experience of a single neurotologist in a busy tertiary
referral practice. Many aspects of neurotologic
diagnosis are quite subjective; different neurotologists presented with the same clinical data might
easily arrive at different formulations of the problem. Furthermore, the results of this study may be
strongly influenced by the case mix; the same
questionnaire applied to a primary care population
or a different otolaryngology practice population
might yield different results. Only experience
gained by using this method in other settings will
Otolaryngology–
Head and Neck Surgery
Volume 128 Number 1
answer the question of its general applicability.
We are starting a study in a different institution to
evaluate this.
The use of a screening questionnaire to evaluate
dizzy patients is no substitute for a neurotologic
evaluation that includes careful history taking, a
detailed otologic and neurologic physical examination, and appropriate diagnostic tests. However,
the efficiency and accuracy of this process can be
enhanced by methods described here. Our classification scheme is based on history alone and can
be self-reported by the patient without a lengthy
interview. It is simple and effective. It permits
rapid and reasonably accurate triage of dizzy patients into diagnostic groups for further work-up
and management. The questionnaire is most effectively used as a base evaluation during the first
office visit. It guides the direction of the diagnostic
work-up. Patients whose flavor of dizziness is
“near syncope” have inadequate cerebral perfusion and can be triaged to the internist or cardiologist, patients with gait dysequilibrium can be
triaged to the neurologist, and the remaining patients can be assessed with this simple dizziness
questionnaire. The majority will be sorted into
correct diagnostic groups before the physical examination and diagnostic work-up are undertaken.
The extended work-up can then be tailored to
answer more specific questions rather than using
the same shotgun approach on every dizzy patient.
Patients who have wandered from physician to
physician seeking diagnosis and treatment are well
served. Physicians frustrated and confused by
dizzy patients gain a logical approach that improves resource utilization and quality of care.
APPENDIX 1: DIZZINESS
QUESTIONNAIRE
Please answer these brief questions about your
dizziness. Circle your answers.
Do you have hearing loss (now or in the
past)?
Yes
No
Do you have TRUE VERTIGO (false sense of
motion, floating, bobbing, swaying, rocking, tilting, or spinning)?
Yes
No
If yes, how long does your vertigo last?
View publication stats
KENTALA and RAUCH 59
1. SHORT EPISODES: less than 5 minutes
2. MODERATE EPISODES: 5 minutes to 24
hours
3. LONG EPISODES: 1 day to 1 week
4. PERSISTENT: longer than 1 week
If no, do you have any of the following symptoms?
A. DYSEQUILIBRIUM (imbalance)
Off-balance, tipsy, wobbly, feeling you might
fall
B. NEAR FAINTING
Feeling you might faint, black out, or lose consciousness
C. SPACEY
Disconnected or distanced from world around
you, panicky, tingling about mouth or hands
How long do these symptoms last?
1. SHORT EPISODES: less than 5 minutes
2. MODERATE EPISODES: 5 minutes to 24
hours
3. LONG EPISODES: 1 day to 1 week
4. PERSISTENT: longer than 1 week
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