What tests can be done for vertigo?

Laboratory and Diagnostic Testing for Vertigo

For a patient experiencing spinning sensations with closed eyes (vertigo), the initial diagnostic approach should prioritize clinical history, physical examination with positional testing (Dix-Hallpike maneuver), and audiometry, while reserving advanced vestibular function testing only for unclear or atypical presentations. 1

Essential First-Line Tests

Clinical Assessment and Positional Testing

• Dix-Hallpike testing is the primary diagnostic maneuver for benign paroxysmal positional vertigo (BPPV), which accounts for 85-95% of positional vertigo cases 1
• Supine roll test evaluates lateral (horizontal) canal BPPV, which represents 5-15% of BPPV cases 1
• Physical examination should include assessment of nystagmus patterns, gait, and balance 1

Audiometric Testing

• Audiogram is mandatory when assessing any patient with vertigo to identify Ménière's disease or other otologic causes 1
• Audiometry helps distinguish between peripheral vestibular disorders with and without hearing loss 1

When Advanced Vestibular Testing Is Appropriate

Indications for ENG/VNG Testing

Advanced vestibular function testing (electronystagmography or videonystagmography) should NOT be routinely ordered but is appropriate when: 2

• Diagnosis remains unclear after clinical examination
• Clinical presentation is atypical for common vestibular disorders
• Positional testing elicits equivocal or unusual nystagmus patterns
• Additional symptoms suggest CNS or otologic disorders beyond typical vestibular presentations
• Multiple concurrent peripheral vestibular disorders are suspected
• Patients remain symptomatic following standard treatment

Components of Comprehensive Vestibular Testing

When indicated, comprehensive testing includes: 1, 2

• Electronystagmography (ENG) or Videonystagmography (VNG): Records nystagmus in response to caloric stimulation, voluntary eye movements, and positional changes
• Vestibular caloric testing: Assesses horizontal semicircular canal function
• Video Head Impulse Test (vHIT): Evaluates high-frequency vestibulo-ocular reflex function 2
• Vestibular Evoked Myogenic Potentials (VEMP): Assesses otolith organ function (saccule and utricle) 2

Tests That Should NOT Be Routinely Ordered

Unnecessary Testing for Clear Diagnoses

• Do not routinely order vestibular function testing to establish the diagnosis of BPPV when diagnostic criteria are met through clinical examination 1, 2
• Do not routinely order vestibular function testing for Ménière's disease with typical history and symptoms 1, 2
• Routine blood tests (complete blood count, serum chemistry) are not indicated unless systemic disease is suspected 1

Imaging Considerations

• MRI of internal auditory canal and posterior fossa may be offered only in patients with non-fluctuating sensorineural hearing loss, tinnitus, or pressure when symptoms are not better accounted for by another disorder 1
• Routine CT or MRI is not indicated for typical BPPV or clear peripheral vestibular disorders 1

Critical Pitfalls to Avoid

Common Testing Errors

• Unnecessary vestibular testing leads to delays in diagnosis and treatment and increases costs without improving outcomes 2
• Normal vestibular test results do not rule out vestibular disorders, particularly Ménière's disease, where test results fluctuate throughout the disease course 2
• The degree of vestibular damage detected on testing correlates poorly with patient-perceived disability 2
• Ordering comprehensive testing for straightforward BPPV delays effective treatment with canalith repositioning procedures 1

Testing Discomfort

• Vestibular function testing can cause significant patient discomfort, including nausea and vertigo during the procedure 2
• This reinforces the importance of reserving such testing only for clinically appropriate situations

Algorithmic Approach to Testing

Step 1: Perform clinical history focusing on triggers (positional vs. spontaneous), timing (seconds vs. hours), and associated symptoms (hearing loss, tinnitus) 1

Step 2: Conduct Dix-Hallpike and supine roll testing to diagnose BPPV 1

Step 3: Obtain audiogram in all patients with vertigo 1

Step 4: If diagnosis is clear (typical BPPV or Ménière's disease), proceed directly to treatment without additional testing 1, 2

Step 5: Reserve ENG/VNG and comprehensive vestibular testing only for atypical presentations, failed treatment, or when diagnosis remains unclear after initial evaluation 2, 3