TY - JOUR
T1 - A New Diagnostic Approach to the Adult Patient with Acute Dizziness
AU - Edlow, Jonathan A.
AU - Gurley, Kiersten L.
AU - Newman-Toker, David E.
N1 - Funding Information:
Dr. Newman-Toker's effort was supported by a grant from the National Institutes of Health (NIDCD U01 DC013778). The funding agency was not involved in design of the study, the collection, analysis, and interpretation of the data, or the decision to approve publication of the finished manuscript. Both Dr. Edlow and Dr. Newman-Toker review medical-legal cases for both plaintiff and defense firms in cases involving neurologic conditions, including dizziness and stroke. Dr. Newman-Toker has conducted funded research related to stroke misdiagnosis and has been loaned research equipment by two commercial companies (GN Otometrics and Interacoustics). Author contributions: JAE wrote the first draft and the diagnostic algorithm. All authors reviewed and edited multiple revisions. JAE takes responsibility for the paper as a whole.
Publisher Copyright:
© 2017 Elsevier Inc.
PY - 2018/4
Y1 - 2018/4
N2 - Background: Dizziness, a common chief complaint, has an extensive differential diagnosis that includes both benign and serious conditions. Emergency physicians must distinguish the majority of patients with self-limiting conditions from those with serious illnesses that require acute treatment. Objective of the Review: This article presents a new approach to diagnosis of the acutely dizzy patient that emphasizes different aspects of the history to guide a focused physical examination with the goal of differentiating benign peripheral vestibular conditions from dangerous posterior circulation strokes in the emergency department. Discussion: Currently, misdiagnoses are frequent and diagnostic testing costs are high. This relates in part to use of an outdated, prevalent, diagnostic paradigm. The traditional approach, which relies on dizziness symptom quality or type (i.e., vertigo, presyncope, or disequilibrium) to guide inquiry, does not distinguish benign from dangerous causes, and is inconsistent with current best evidence. A new approach divides patients into three key categories using timing and triggers, guiding a differential diagnosis and targeted bedside examination protocol: 1) acute vestibular syndrome, where bedside physical examination differentiates vestibular neuritis from stroke; 2) spontaneous episodic vestibular syndrome, where associated symptoms help differentiate vestibular migraine from transient ischemic attack; and 3) triggered episodic vestibular syndrome, where the Dix-Hallpike and supine roll test help differentiate benign paroxysmal positional vertigo from posterior fossa structural lesions. Conclusions: The timing and triggers diagnostic approach for the acutely dizzy patient derives from current best evidence and offers the potential to reduce misdiagnosis while simultaneously decreases diagnostic test overuse, unnecessary hospitalization, and incorrect treatments.
AB - Background: Dizziness, a common chief complaint, has an extensive differential diagnosis that includes both benign and serious conditions. Emergency physicians must distinguish the majority of patients with self-limiting conditions from those with serious illnesses that require acute treatment. Objective of the Review: This article presents a new approach to diagnosis of the acutely dizzy patient that emphasizes different aspects of the history to guide a focused physical examination with the goal of differentiating benign peripheral vestibular conditions from dangerous posterior circulation strokes in the emergency department. Discussion: Currently, misdiagnoses are frequent and diagnostic testing costs are high. This relates in part to use of an outdated, prevalent, diagnostic paradigm. The traditional approach, which relies on dizziness symptom quality or type (i.e., vertigo, presyncope, or disequilibrium) to guide inquiry, does not distinguish benign from dangerous causes, and is inconsistent with current best evidence. A new approach divides patients into three key categories using timing and triggers, guiding a differential diagnosis and targeted bedside examination protocol: 1) acute vestibular syndrome, where bedside physical examination differentiates vestibular neuritis from stroke; 2) spontaneous episodic vestibular syndrome, where associated symptoms help differentiate vestibular migraine from transient ischemic attack; and 3) triggered episodic vestibular syndrome, where the Dix-Hallpike and supine roll test help differentiate benign paroxysmal positional vertigo from posterior fossa structural lesions. Conclusions: The timing and triggers diagnostic approach for the acutely dizzy patient derives from current best evidence and offers the potential to reduce misdiagnosis while simultaneously decreases diagnostic test overuse, unnecessary hospitalization, and incorrect treatments.
KW - BPPV
KW - diagnosis
KW - dizziness
KW - misdiagnosis
KW - nystagmus
KW - posterior circulation stroke
KW - vertigo
KW - vestibular neuritis
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U2 - 10.1016/j.jemermed.2017.12.024
DO - 10.1016/j.jemermed.2017.12.024
M3 - Article
C2 - 29395695
AN - SCOPUS:85041568117
SN - 0736-4679
VL - 54
SP - 469
EP - 483
JO - Journal of Emergency Medicine
JF - Journal of Emergency Medicine
IS - 4
ER -