Dizziness: Approach to Evaluation and Management

Dizziness is a common yet imprecise symptom. It was traditionally divided into four categories based on the patient’s history: vertigo, presyncope, disequilibrium, and light-headedness. However, the distinction between these symptoms is of limited clinical usefulness | American family Physician


Patients have difficulty describing the quality of their symptoms but can more consistently identify the timing and triggers. Episodic vertigo triggered by head motion may be due to benign paroxysmal positional vertigo. Vertigo with unilateral hearing loss suggests Meniere disease. Episodic vertigo not associated with any trigger may be a symptom of vestibular neuritis. Evaluation focuses on determining whether the etiology is peripheral or central. Peripheral etiologies are usually benign. Central etiologies often require urgent treatment. The HINTS (head-impulse, nystagmus, test of skew) examination can help distinguish peripheral from central etiologies. The physical examination includes orthostatic blood pressure measurement, a full cardiac and neurologic examination, assessment for nystagmus, and the Dix-Hallpike maneuver. Laboratory testing and imaging are not required and are usually not helpful. Benign paroxysmal positional vertigo can be treated with a canalith repositioning procedure (e.g., Epley maneuver). Treatment of Meniere disease includes salt restriction and diuretics. Symptoms of vestibular neuritis are relieved with vestibular suppressant medications and vestibular rehabilitation.

Full reference: Muncie, H. et al. (2017) Dizziness: Approach to Evaluation and Management. American Family Physician. Vol. 95 (no. 3) pp. 154-162.

MRI for residual and recurrent cholesteatoma

Diagnosis and management of recurrent or residual cholesteatoma can be problematic. Diffusion-weighted imaging magnetic resonance imaging (MRI) sequences have been used for follow-up of such lesions

Objective of review: Evaluate whether diffusion-weighted magnetic resonance imaging is useful in the diagnosis of recurrent or residual cholesteatoma.


Results: A total of 575 studies were identified of which 27 met the inclusion criteria. These covered 727 patient episodes. For EPI studies: sensitivity (sd) 71.82 (24.5), specificity (sd) 89.36 (13.4), PPV (sd) 93.36 (8.1) and NPV (sd) 73.36 (15.8). For non-EPI studies: sensitivity 89.79 (12.1), specificity (sd) 94.57 (5.8), PPV (sd) 96.50 (4.2) and NPV 80.46 (20.2). Improved sensitivity of non-EPI sequences reached significance (P = 0.02).

Conclusions: Diffusion-weighted MRI is both sensitive and specific for the detection of recurrent or residual cholesteatoma following ear surgery. Non-EPI techniques are superior to EPI techniques.

Full reference: Muzaffar, J. et al. (2017) Diffusion-weighted magnetic resonance imaging for residual and recurrent cholesteatoma: a systematic review and meta-analysis. Clinical Otolaryngology. 42(3) pp. 536–543