Chapter 3
Diagnosing Dizziness and Vertigo:
The Physical Exam and Balance Testing
Steven A. Telian, M.D.

University of Michigan
Department of Otology
Ann Arbor, Michigan

Your doctor should have a good idea of the probable diagnosis before even proceeding on to the next steps of examination and testing. Sometimes, your doctor can even make the correct diagnosis without any testing. Since almost all causes of dizziness share some common symptoms, it is the nature and pattern of those symptoms at onset and then how they develop over time that provides the key to correct diagnosis and treatment. So, please be very careful to organize your experiences in your own mind and as previously emphasized, pay careful attention to answer the doctor’s specific questions when giving your medical history. Once your doctor has completed the history, he or she will decide what parts of the balance system need to be examined and what tests will be obtained, if any. My goal in this chapter is to help you understand and anticipate what will happen to you during this phase of the evaluation.

The Physical Examination for Dizziness

After a careful medical history, you should receive an examination from an otologist or neurotologist (an ear surgeon who has taken additional training in neurology, neurosurgery and skull-base surgery to treat advanced problems involving the ear, inner ear and the region around the ear and the temporal bone). This will include both an examination of the ears, nose and throat as well as a screening neurologic examination related to the balance system. The entire exam portion may be conducted efficiently in about ten minutes, particularly if there are few abnormalities noted.

Examination of the Ears, Nose and Throat

. . . If the appearance of the ear is normal, but the medical history suggests a possible injury to the tiny membranes that retain the inner ear fluids, the doctor may be suspicious of a perilymphatic fistula. Perilymph is the fluid contained in the outer chamber of the inner ear and surrounds the inner chamber that contains endolymph. A fistula is a leakage of the perilymph fluid from the inner ear to the air-filled middle ear. The most common site for the perilymphatic fistula is through the inner ear’s round window membrane which is a thin film in the cochlea.

If the doctor suspects a perilymphatic fistula, he will perform what is called a “fistula test.” This test involves sealing the ear canal, then gently increasing and decreasing the pressure on the eardrum. These pressure changes produce a similar change in the middle ear pressure. When there’s a fistula present, one of the inner ear fluids (called perilymph) may be able to leak out through an abnormal connection between the middle ear and the inner ear.

In such cases, the pressure change in the middle ear will irritate your inner ear, provoking dizziness. The doctor will ask you if you experience dizziness with positive pressure, negative pressure or both. There may be another member of the medical staff in the room to observe your eyes during the fistula test, since inner ear disturbances are usually reflected in predictable but abnormal movements of the eyes. . .