Introduction
Before the scanner, the bedside.
For the dizzy patient the most powerful diagnostic instrument is still a careful examiner. A handful of bedside tests, performed in the right order, separates the benign from the dangerous more reliably than any imaging study at 24 hours.
- 0%lifetime prevalence of vertigo in the general populationNeuhauser 2007
- 0%of acute vestibular syndromes are strokes — not neuritisTarnutzer 2011 · Kim & Lee 2012
- 0%of BPPV is in the posterior canal — Dix-Hallpike-detectablevon Brevern 2007
- 0%stroke detection by the central HINTS pattern in expert handsKattah 2009 (Stroke)
Most dizziness is benign. A small but important fraction is dangerous. The bedside examination is how we tell the two apart — and, for most peripheral causes such as BPPV, it is the diagnostic AND the path to treatment.
This chapter is a guided tour of the bedside examination for vertigo. It starts with the general physical exam — vital signs, heart, neurological exam, ears — and moves through the vestibular-specific manoeuvres: the Dix-Hallpike for BPPV, the head impulse test for the vestibulo-ocular reflex, observing nystagmus, the test of skew, and balance tests (Romberg, Fukuda, tandem gait).
Around 30% of people experience vertigo at some point in life and dizziness drives a sizeable share of emergency and ENT/neurology presentations. About a quarter of patients with acute vestibular syndrome (AVS) have a posterior-circulation stroke rather than vestibular neuritis,2 yet early diffusion-weighted MRI misses ~10–20% of small posterior-fossa infarcts in the first 24–48 hours.3
In that window a focused bedside oculomotor exam — the HINTS battery — is more sensitive than MRI for posterior-circulation stroke when performed by a trained clinician.1 For the much commoner peripheral cause, BPPV, the Dix-Hallpike has 79–88% sensitivity and approaches perfect specificity, with ~85% of BPPV in the posterior canal alone.4
The chapter is organised by what you ask the patient to do at the bedside: a brief general exam to catch the systemic mimics (orthostatic hypotension, arrhythmias, metabolic/endocrine), then positional manoeuvres (Dix-Hallpike, Supine Roll, Straight Head Hanging), the head impulse test, bedside nystagmus characterisation, the test of skew and HINTS interpretation, and stance/gait assessment.5
Each section pairs the manoeuvre with what it can and cannot tell you, the pitfalls that produce false positives or negatives, and the threshold at which the bedside gives way to imaging or quantitative testing (video-oculography, vHIT, audiometry).