Medical Excellence- Issue 1

benign or peripheral vestibular diagnosis return to the ED within 30 days and are hospitalized with a cerebrovascular diagnosis [36–38]. However, because dizziness is so common, this small fraction of a large number would suggest that many thousands of patients have a missed diagnosis of an acute cerebrovascular syndrome (stroke or transient ischemic attack [TIA]) each year. The other side of the coin is that a lack of recognition of common peripheral vestibular problems (such as BPPV and vestibular neuritis) can result in undertreatment, incorrect treat- ment, and resource overutilization. A recent review of misdiagnosis of patients with dizziness suggested five common pitfalls [39]. These are overreliance on a symptom quality approach to diagnosis, underuse of timing and triggers approach, lack of familiarity with key physical examina- tion findings, overweighting traditional factors such as age and vascular risk factors to screen patients, and overreliance on CT. Although stroke is more common in older individuals, young pa- tients do have strokes, a fact that may contribute to misdiagnosis [5, 40, 41]. A New Paradigm to Diagnose Patients with Acute Dizziness: ATTEST A new diagnostic paradigm which is based on the timing, trig- gers, and context of the dizzy symptoms might reduce misdiag- nosis and decrease unnecessary resource utilization. My person- al experience is that it allows one to confidently make a specific diagnosis more frequently than the traditional paradigm. The basic idea is that it is the timing, triggers, evolution, and context of symptoms that should drive the workup rather than the spe- cific words that a patient uses to describe their dizziness [6, 21]. I favor the mnemonic: ATTEST—which stands for A ( a ssociated symptoms), TT ( t iming and t riggers), ES (bedside e xam s igns), and T (additional t esting as needed). This new paradigm may seem like a radically new way of ap- proaching the dizzy patient, but this is only because the traditional “symptom quality” approach is so deeply engrained in how this subject has been taught [21]. In fact, using a timing and triggers approach is no different than taking a history in any other patient. Using this paradigm, there are four timing and triggers cat- egories that are important for emergency physicians (Table 3). In the traditional paradigm, a patient who endorsed “vertigo” would get an evaluation to try to diagnose peripheral vestibular versus central nervous system (CNS) causes of dizziness. This has led to confusion. Physicians tend to treat all patients with peripheral vertigo the same, whereas the two most common by far being BPPV and vestibular neuritis should be treated very dif- ferently [7]. The following sections will review the presentation, differential diagnosis, and appropriate testing to make a specific diagnosis for each of the timing and triggers categories. Acute Vestibular Syndrome (AVS) Spontaneous AVS is defined as the acute onset of persistent diz- ziness in association with nausea or vomiting, gait instability, nystagmus, and head-motion intolerance that lasts days or weeks and gradually resolves [6, 21, 42]. Patients are usually sympto- matic at the time of assessment, and focused physical examina- tion is often diagnostic. The most common cause is vestibular neuritis (dizziness only) or labyrinthitis (dizziness plus hearing loss or tinnitus) [42]. The most frequent dangerous cause is pos- terior circulation ischemic stroke, generally in the cerebellum or lateral brain stem [42]. A distant third most common cause is multiple sclerosis [43, 44]. Uncommon causes of an isolated AVS include cerebellar hemorrhage and a number of rare, but often treatable, autoimmune, infectious, or metabolic conditions [43, 45]. The spontaneous AVS is to be distinguished from a triggered AVS, which we will not further discuss in this paper because the cause is usually obvious, such as post-traumatic dizziness or di- phenylhydantoin toxicity. An important concept is that patients with an AVS gener- ally experience worsening of their symptoms with head move- ment. These exacerbating features should not be mistaken for head movement triggers that facilitate diagnosis in EVS patients. Confusion on this point probably contributes to difficulty differ- entiating BPPV from vestibular neuritis [6, 7, 46]. Acute BPPV patients occasionally complain of more persistent symptoms that may be due to repeated triggering symptoms with small, inad- vertent head movements or anticipatory anxiety about moving. This can usually be teased out by careful history taking. When such patients lack obvious features of vestibular neuritis or stroke, the Dix-Hallpike and supine roll test can be performed to assess for an atypical, AVS-like presentation of BPPV [47]. Vestibular neuritis is a benign, self-limited, presumed viral, or post-viral inflammatory condition affecting the vestibu- lar nerve and causing spontaneous AVS, similar to Bell’s palsy (seventh nerve) but involving the vestibular portion of the eighth nerve. Some cases are associated with inflammatory disorders (e.g., multiple sclerosis or sarcoidosis), but most are idiopathic and possibly linked to herpes simplex infections [48]. The idi- opathic form is generally monophasic and resolves over days to weeks. Routine MRI with contrast is generally negative [49]. The diagnosis is usually clinical. A related condition, herpes zoster oticus (Ramsay Hunt syndrome type 2), may present with AVS, usually in conjunction with hearing loss, facial palsy, and a vesicular eruption in the ear or palate [50]. Issue-1  |  5 MEDICAL EXCELLENCE