Misdiagnosing Dizzy Patients

Kerber, Kevin A.; Newman‐Toker, David E.

doi:10.1016/j.ncl.2015.04.009

Cited by 98 publications

(74 citation statements)

References 51 publications

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“…Patients should be able to consistently choose one (and only one) dizziness type and each symptom type should be tightly linked with a given differential diagnosis. Both are demonstrably false (6,16,17). …”

Section: Discussionmentioning

confidence: 99%

“…Patients with benign paroxysmal positional vertigo (BPPV) often describe non-vertiginous dizziness, especially in elderly patients (22). Despite these newer data, most physicians still use a symptom-quality approach with dizzy patients without considering the timing and triggers (6,23). …”

Section: Discussionmentioning

confidence: 99%

“…Knowledge gaps regarding eye-movement findings also contribute to misdiagnosis (6). In a study of 1091 dizzy patients in U.S. EDs, physicians used templates to document the presence or absence of nystagmus in 887 (80%).…”

Section: Diagnostic Pitfallsmentioning

confidence: 99%

“…Misdiagnosis of patients with dizziness results from five common pitfalls: over-reliance on a symptom-quality approach to diagnosis, underuse of a timing and triggers approach, lack of familiarity with key physical examination findings, overweighting traditional factors such as age and vascular risk factors to screen patients, and over-reliance on computed tomography (CT) (6). Not considering stroke in young patients is a particularly important contributing factor (30,35).…”

Section: Diagnostic Pitfallsmentioning

confidence: 99%

“…The existing diagnostic paradigm for dizziness, based on symptom quality or type of dizziness (i.e., asking the question “what do you mean ‘dizzy’?”), is taught across specialties; however, newer research has questioned its scientific basis (6). Taking a history from a dizzy patient should be no different than taking a history in other patients.…”

Section: Introductionmentioning

confidence: 99%

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A New Diagnostic Approach to the Adult Patient with Acute Dizziness

Edlow

Gurley

Newman‐Toker

2018

The Journal of Emergency Medicine

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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.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Diagnostic Pitfallsmentioning

confidence: 99%

Section: Diagnostic Pitfallsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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A New Diagnostic Approach to the Adult Patient with Acute Dizziness

Edlow

Gurley

Newman‐Toker

2018

The Journal of Emergency Medicine

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Correct Diagnosis for the Proper Treatment of Acute Vertigo—Putting the Diagnostic Horse Before the Therapeutic Cart

2022

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This issue of JAMA Neurology includes a methodologically rigorous systematic review and meta-analysis examining the efficacy of benzodiazepines and antihistamines in patients with acute vertigo. 1 Hunter and colleagues 1 chose an important, common clinical problem, systematically searched for relevant evidence, and then assessed the studies for both quality and risk of bias. Their primary outcome was symptom control of vertigo at 2 hours measured by a visual analog score. Secondary outcomes included symptom control at later time points. Symptom control is clearly an important patient-centric outcome; therefore, their study is relevant and timely.Hunter and colleagues 1 found that antihistamines were superior to benzodiazepines at 2 hours but not at 1 week or 1 month. Importantly, as the authors themselves acknowledge, we do not know if the statistically significant difference in self-rated symptom severity is clinically meaningful. Of the 16 studies analyzed, 9 of them gave the vestibular suppressant for "1 week to 2 months." 1 This duration of medication was in the setting of clinical trials; however, in real-life practice, patients often continue treatment with vestibular suppressants for far longer periods of time. 2,3 Of course, correct treatment of acute vertigo depends on first making a correct diagnosis-something that cannot necessarily be taken for granted. It is worth noting that Hunter et al 1 included studies of patients with acute vertigo of any cause. However, comparing symptomatic treatments for patients with acute vertigo without first determining a specific central or peripheral vestibular diagnosis ignores an enormous body of clinically relevant literature that supports disease-specific treatment. Imagine 3 emergency department (ED) patients with isolated acute vertigo or dizziness. One has typical benign paroxysmal positional vertigo (BPPV), one has vestibular neuritis, and the third has an ischemic cerebellar stroke. The study by Hunter et al 1 shows that antihistamines are more effective than benzodiazepines at controlling acute symptoms, but that is only 1 component of best management. Clearly, the ideal strategy would be to begin with a correct diagnosis, then treat accordingly in disease-specific fashion: (1) canalith repositioning maneuver for BPPV, (2) corticosteroids plus short-term (ie, 3-5 days) vestibular suppressants (Hunter and colleagues 1 would say antihistamines) and early vestibular rehabilitation for vestibular neuritis, and (3) dual antiplatelet therapy as emergent secondary prevention (or other appropriate acute stroke treatment) for the patient with posterior circulation ischemia.

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Video-Oculography to Guide Neuroimaging for Dizziness and Vertigo

Kattah

Newman‐Toker

2022

JAMA Otolaryngol Head Neck Surg

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Dizziness and vertigo are among the most common presenting symptoms in both the emergency department (ED) and ambulatory outpatient clinics, with recent estimates suggesting roughly 18 million visits per year in the US (nearly 5 million to EDs and >13 million to outpatient clinics). 1 These symptoms are caused by a wide array of conditions, but the most common benign causes are otologic, and the most common dangerous cause is stroke.

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Misdiagnosing Dizzy Patients

Cited by 98 publications

References 51 publications

A New Diagnostic Approach to the Adult Patient with Acute Dizziness

A New Diagnostic Approach to the Adult Patient with Acute Dizziness

Correct Diagnosis for the Proper Treatment of Acute Vertigo—Putting the Diagnostic Horse Before the Therapeutic Cart

Video-Oculography to Guide Neuroimaging for Dizziness and Vertigo

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