ENT special tests: central vs peripheral vertigo
Introduction
Vertigo presenting to the ED requires early differentiation between peripheral vestibular causes (inner ear/labyrinth or vestibular nerve) and central causes (brainstem/cerebellum, including posterior circulation stroke). Bedside vestibular and oculomotor testing gives immediate, high‑value information to guide management and disposition.
Use positional testing (Dix-Hallpike) for suspected BPPV and the HINTS exam for acute vestibular syndrome (AVS) only when clinicians are trained in its performance and interpretation (NICE NG127, QS198). When HINTS cannot be performed reliably, escalate via local stroke pathways (NICE NG127, NG128).
Clinical syndromes - choose tests to match the presentation
- Brief, positional rotational vertigo (seconds): suspect posterior‑canal BPPV. Perform Dix-Hallpike and offer canalith repositioning (Epley) if positive (NICE NG127, QS198).
- Acute vestibular syndrome (AVS): sudden continuous vertigo for hours-days with nausea/vomiting, spontaneous nystagmus, and gait unsteadiness. Consider vestibular neuritis versus posterior circulation stroke. Perform HINTS (Head‑Impulse, Nystagmus, Test‑of‑Skew) only if a trained clinician is available; otherwise treat as possible central and follow local stroke pathway (NICE NG127, NG128).
- Intermittent or episodic dizziness with other features: tailor testing and safety‑netting to the clinical picture and look for red flags.
Red flags mandating urgent referral/imaging
Any of the following with acute dizziness/vertigo should prompt immediate stroke‑pathway consideration and urgent neuroimaging (treat as possible posterior circulation stroke) (NICE NG127, NG128):