The Bedside Examination

Dizziness accounts for ~3% of emergency-department visits. The most important branch-point is whether the presentation fits an acute vestibular syndrome (AVS) — rapid-onset vertigo lasting days, nausea/vomiting, gait unsteadiness, head-motion intolerance, spontaneous nystagmus. In AVS, the question becomes: is this peripheral (e.g., vestibular neuritis) or central (e.g., posterior fossa stroke)? The TiTrATE framework reframes the dizzy patient by Timing, Triggers and Targeted Exam — sorting presentations into four broad vestibular syndromes that drive very different workups.

CVS is the bin most often missed in the emergency department because the patient is rarely in extremis: dizziness is constant but low-grade, and the bedside exam is often normal. These patients usually present to outpatient clinics, not the ED, and the diagnosis rests more on history pattern and vestibular function testing than on a single examination finding.

1. 1.
   Spontaneous nystagmus in primary gaze

   With fixation, then again after fixation is removed (Frenzel lenses, video-Frenzel, or look at the eyes with a +20 D lens / ophthalmoscope while the other eye fixates a target).
2. 2.
   Range of EOM motion

   Test the 9 cardinal gaze positions. Look for an adduction deficit (INO), upgaze palsy (dorsal midbrain), or any restricted movement.
3. 3.
   Ocular alignment

   Cover-uncover and alternate cover tests to detect tropias/phorias. Vertical misalignment (skew) is a central sign in AVS.
4. 4.
   Pupils

   Anisocoria, light response, RAPD (Horner's accompanies Wallenberg lateral medullary syndrome).
5. 5.
   Gaze-evoked nystagmus

   Hold gaze 15–20° eccentric for ≥10 seconds in 4 cardinal positions. A few unsustained beats at extremes = physiologic end-point; sustained = pathologic.
6. 6.
   Saccades

   Quick gaze shifts between two targets. Look for slowing (INO, brainstem), inaccuracy (cerebellum: hypermetria), latency, or initiation difficulty.
7. 7.
   Smooth pursuit

   Track a slowly moving finger. Saccadic ('cogwheel') pursuit = cerebellar/age/sedation.

With the patient fixating your nose, deliver a small (~15°), fast, and unpredictable head turn. Watch the eyes. A normal VOR keeps the eyes locked on your nose (eyes counter-rotate equally to the head). An abnormal VOR produces a visible corrective ("catch-up") saccade back to the target after the head movement — the cardinal sign of peripheral vestibular hypofunction toward that side.

To characterize nystagmus, observe in five conditions: primary gaze with fixation, primary gaze without fixation(Frenzel / video-Frenzel goggles), eccentric gaze in 4 directions, after head-shaking (15 cycles 2 Hz then watch), and in positions of provocation (Dix-Hallpike, roll test). Each tells you something different about where the lesion is.

Vertical ocular misalignment (skew deviation) is a hallmark of brainstem dysfunction, especially involving the otolith-ocular pathway from the utricle through the vestibular nuclei to the riMLF. Test by holding the patient's gaze on a target while alternately covering each eye every 1–2 seconds. A vertical refixation movement of the uncovered eye = skew.

HINTS = Head Impulse + Nystagmus + Test of Skew. In a patient with the acute vestibular syndrome, the combination distinguishes peripheral from central with sensitivity approaching 100% for stroke when performed by a trained clinician — exceeding early MRI-DWI^[1]. "HINTS+" adds a finger-rub hearing test (unilateral hearing loss in AVS suggests AICA stroke, since the cochlea is supplied by the internal auditory artery, a branch of AICA)^[2,3].

The diagnostic test for posterior (and anterior) canal BPPV. Move through the five steps; on the right is what you should see in the patient's eyes at each step.

The horizontal canal is in the gravity plane when the patient is supine with head flexed ~30°. Rolling the head 90° to each side stimulates the affected horizontal canal. The nystagmus is purely horizontal^[5,4].