Summary of our approach to the patient with chronic vestibular symptoms (slightly modified from Bronstein and Lempert31)
| Approach | Specific goals—try to establish: |
|---|---|
| Attempt retrospective diagnosis | Did it all start as BPPV, vestibular neuritis, recurrent vertigo (eg, migraine, Ménière's disease), brainstem stroke? |
| Are the original symptoms still present? | |
| Or are we only dealing with chronic dizzy symptoms? | |
| Other potentially important problems | Is vestibular compensation impeded due to additional problems? |
| Fluctuating vestibular disorder, recurrent vertigo | |
| Visual problems such as squint, cataract operation | |
| Proprioceptive deficit such as peripheral neuropathy (diabetes/alcohol) | |
| Neurological problems such as ‘small vessel’ white matter disease | |
| Orthopaedic problems and lack of mobility | |
| Loss of confidence, fear of falling, psychological disorders | |
| Age: all of the above possible but try to identify which one(s) | |
| Treatment is multidisciplinary | Treat any episodic vertigo specifically: |
| BPPV: repositioning manoeuvres | |
| Vestibular migraine: migraine prophylaxis | |
| Ménière's disease: low salt diet, diuretics,betahistine | |
| Rehabilitation (and simple counselling): all patients | |
| Treat underlying complicating factors: eg,orthopaedic, depression, diabetes, migraine | |
| Do not prescribe vestibular suppressants or tranquilisers, stop/reduce them if possible | |
| Make sure the ‘chronic dizziness’ is not a gait disorder | ‘Is your problem a head problem or a leg problem?’ Ask about falls |
| Observe: gait (including heel to toe), postural reactions and Romberg's sign | |
| Eye movement and neurological examination: | |
| Bilateral vestibular failure: oscillopsia, unsteady in the dark, abnormal doll's head/head thrust test | |
| Cerebellum: abnormal eye movements, gait/limb ataxia | |
| Parkinsonism: rest tremor, increased tone, akinesia | |
| Spasticity: increased reflexes, Babinski's sign | |
| Peripheral neuropathy: distal weakness (cannot walk on heels or toes) and sensory loss | |
| Frontal disorder/hydrocephalus: gait ‘ignition’ failure, gait apraxia, shuffling |
BPPV, benign paroxysmal positional vertigo.