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ORIGINAL ARTICLE

Dizziness, A Review of Walk-In Patients at a Specialised

Neurotology Clinic
R Philip, MMed ORL-HNS, N Prepageran, FRCS

Department of ENT, Universiti Malaya Medical Centre, Hospital Raja Permaisuri Bainun Ipoh, Jalan Hospital, 30990, Ipoh, Perak

SUMMARY Following the history taking and clinical examination,

A retrospective review of 100 walk-in patients at a further audiological and vestibular investigations were
specialized neurotology clinic in dizziness at a tertiary ordered as necessary. These included audiometry, a full
referral centre is presented. The most common cause of electronystagmography (ENG) test, caloric tests and dynamic
dizziness was BPPV, forming 31% of the cases. Other causes postulography. MRI or a CT scan was done if a central cause
in order of frequency include recurrent vestibulopathy, was suspected.
idiopathic causes, Meniere’s disease and central causes.
Once a diagnosis is established, the patients are referred back
KEY WORDS: to the primary referral unit for follow-up and continued
Vertigo, Dizziness, Benign paroxysmal positional vertigo (BPPV) management.

INTRODUCTION RESULTS
Dizziness is a non-specific complaint of unsteadiness or A total of 100 patients were included in the study. The male
imbalance which can originate from disorders of many to female ratio was almost 1:1 with 49 males and 51 females.
systems including the peripheral vestibular system, central The ethnic breakdown of these patients was Chinese 43,
nervous system, cardiovascular system, drugs or even followed by Indians 29 and Malays 28.
psychogenic. Vertigo is defined as an illusion of movement
and is a symptom of a disorder of the vestibular system. It can The majority of the patients, 88% were above the age of 40.
be peripheral or central in origin. The vestibular system is There was one patient at age 11 and two in their twenties.
frequently implicated as a cause of dizziness and a common The mean age of male patients was 53.1 and female patients
cause of referrals to the ENT clinic. The specialized 51.6 years. (Fig.1)
neurotology clinic in Universiti Malaya Medical Center was
set up in 2004 to systematically evaluate patients from Peripheral vestibular causes accounted for 66% of the patients
medical, paediatric, psychiatric, neurosurgical and ENT in this review. Benign Paroxysmal Positional Vertigo (BPPV)
clinics that required further evaluation for dizziness. was the most common diagnosis, with 31% of the patients.
This was followed by Recurrent Vestibulopathy (RV) at 29%.
In 27 cases no cause was identifiable. In the last category,
MATERIALS AND METHODS “others”, one patient had a psychogenic cause; one had high
The study is a retrospective review of case-records of patients frequency hearing loss; another had post-traumatic dizziness
seen at the specialized neurotology clinic Universiti Malaya while the last was due to postural hypotension. (Table I). The
Medical Centre for a two year period from 2004 to 2006. three patients with central causes were due to posterior fossa
Most of these patients were referred from the ENT clinic and tumors.
Neurosurgical clinic of University Malaya Medical Centre and
ENT clinics from Klang Valley region. All patients seen at the Nineteen patients had hypertension and two patients had
clinic, a total of 100 patients were included in the study. diabetes mellitus.

The patients were interviewed and a detailed history was

taken regarding their symptoms. A general examination was DISCUSSION
performed including a neurological assessment with Dizziness always presents as a challenge to the clinician. The
particular emphasis on cranial nerves, cerebellar and gait term itself is non-specific and encompasses a wide range of
evaluation. symptoms including light-headedness, imbalance, fainting
spells and disequilibrium. The patients themselves are
Otologic examination consisted of otoscopy and tuning fork usually middle-aged and often with other co-morbid factors.
tests. Oculomotor and special tests of vestibular function As such doctors in various settings and specialities often face
were then performed. These included the Halmagyi patients with ‘giddy’ or ‘dizzy’ patients.
maneuver, head shake test, oscillopsia test and vestibular
ocular reflex (VOR) suppression. Finally a Dix-Hallpike These patients are often referred to an ENT unit to rule out a
positional test and hyperventilation test for 60 seconds were vestibular cause. Vestibular disorders can be of peripheral or
performed. central in origin. Peripheral vestibular disorders stem from
This article was accepted: 17 February 2009
Corresponding Author: Philip Rajan, Pakar ENT, Jabatan ENT, Hospital Raja Permaisuri Bainum Ipoh, Jalan Hospital, 30990, Ipoh, Perak
Email: prajan333@[Link]

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Dizziness, A Review of Walk-In Patients at a Specialised Neurotology Clinic

Table I: Diagnosis of dizzy patient

Diagnosis No of Patients
Recurrent Vestibulopathy (RV) 29
Benign Paroxysmal Positional Vertigo (BPPV) 31
Delayed Endolymphatic Hydrops (DEH) 2
Meniere’s Disease 4
Central 3
Idiopathic 27
Others 4

Table II: Causes of Peripheral Vertigo from Malaysian series

Peripheral Vestibular Disorder (%) RD Ponniah (1977) G Krishnan (1994) Present Study
BPPV 14 5.6 31
Recurrent Vestibulopathy 29
Meniere’s Disease 8.5 22.4 4
Delayed Endolymphatic Hydrops 2
Vestibular Neuronitis 18 4.7
Ototoxicity 1.5
Vestibular Insufficiency 0.9
Total 42 38.3 66

questioned2. Data from this institution correlating the

accuracy of these tests with the diagnosis is currently under
study.

The majority of the patients in this series were above the age
of 40. The peak incidence was in the 5th and 6th decades of
life. This differs slightly from two previous studies at this
institution where there is a slightly younger preponderance.
However this may be reflective of the nature of referrals to
this clinic. Acute causes of vertigo such as vestibular
neuronitis were fairly common in those series and affected a
younger population3,4 . (Table II) Such cases would have been
successfully managed by the attending physician and would
Fig. 1: Age distribution of patients not have required a referral to the unit.

In this series, 66% of the patients had a peripheral vestibular

pathologies affecting the vestibular apparatus of the inner ear cause for their dizziness. Similar studies at this institution in
and vestibular nerve. These include BPPV, vestibular the past showed a peripheral vestibular cause at 42%3 and
neuronitis, Meniere’s disease, labyrinthittis, perilymphatic 38.3%4 respectively. The incidence of a peripheral vestibular
fistula and superior semi-circular canal dehiscience. Central cause from other series ranges from 38 – 64.7%5-7.
disorders are those conditions affecting the central nervous
system such as strokes, tumors, aneurysms and multiple BPPV was the most common peripheral vestibular cause in
sclerosis. our series with a prevalence of 31%. Similarly other studies
have reported BPPV to be the leading cause of peripheral
A detailed history is mandatory to arrive at a diagnosis. This vertigo with an incidence of 12%- 36.5%5-7.
is complemented by a complete physical examination with
an emphasis on postural blood pressure, cardiovascular, Recurrent vestibulopathy (RV) was second most common
neurological and ENT examination. cause of dizziness. RV is a clinical syndrome of unknown
aetiology that is characterized by more than a single episode
At the neurotology clinic a series of clinical maneuvers are of vertigo similar to Meniere’s (i.e. lasting from a few minutes
applied on the patient. These tests are the ‘Halmagyi’ test or up to 24 hours) but without auditory or neurological signs
head thrust, head shake test, oscillopsia, vestibule-ocular and symptoms7,8. At the University of Toronto,
reflex (VOR) suppression. These clinical tests are specific for multidisciplinary clinic, RV was similarly found to be the
the VOR and aid in the diagnosis of a peripheral vestibular second most common cause of peripheral vertigo7. Long term
disorder. Oscillopsia is blurring of vision following head follow-up of up to 8.5 years of patients diagnosed with RV at
movement and occurs in bilateral peripheral vestibular loss as that centre showed a change in diagnosis in 22% of the
in gentamicin vestibulotoxocity1. Special vestibular patients (14% Meniere’s disease and 8% BPPV)7,9. The
investigations such as caloric tests, electronystagmography prognosis for spontaneous resolution of RV is good, with two
(ENG) test and dynamic postulography were ordered as thirds of the patients experiencing complete resolution of
necessary. The value of these specialized tests has been vertigo over a follow-up period of 8.5 years9.

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Original Article

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