Uso del examen físico para diagnosticar a pacientes con mareos agudos y vértigo

Abstract

Background: Emergency department (ED) patients who present with acute dizziness or vertigo can be challenging to diagnose. Roughly half have general medical disorders that are usually apparent from the context, associated symptoms, or initial laboratory tests. The rest include a mix of common inner ear disorders and uncommon neurologic ones, particularly vertebrobasilar strokes or posterior fossa mass lesions. In these latter cases, misdiagnosis can lead to serious adverse consequences for patients.

Objective: Our aim was to assist emergency physicians to use the physical examination effectively to make a specific diagnosis in patients with acute dizziness or vertigo.

Discussion: Recent evidence indicates that the physical examination can help physicians accurately discriminate between benign inner ear conditions and dangerous central ones, enabling correct management of peripheral vestibular disease and avoiding dangerous misdiagnoses of central ones. Patients with the acute vestibular syndrome mostly have vestibular neuritis, but some have stroke. Data suggest that focused eye movement examinations, at least when performed by specialists, are more sensitive for detecting early stroke than brain imaging, including diffusion-weighted magnetic resonance imaging. Patients with the triggered episodic vestibular syndrome mostly have benign paroxysmal positional vertigo (BPPV), but some have posterior fossa mass lesions. Specific positional tests to provoke nystagmus can confirm a BPPV diagnosis at the bedside, enabling immediate curative therapy, or indicate the need for imaging.

Conclusions: Emergency physicians can effectively use the physical examination to make a specific diagnosis in patients with acute dizziness or vertigo. They must understand the limitations of brain imaging. This may reduce misdiagnosis of serious central causes of dizziness, including posterior circulation stroke and posterior fossa mass lesions, and improve resource utilizatio

Edlow JA, Newman-Toker D. Using the Physical Examination to Diagnose Patients with Acute Dizziness and Vertigo. J Emerg Med. 2016 Apr;50(4):617-28. doi: 10.1016/j.jemermed.2015.10.040. Epub 2016 Feb 16. PMID: 26896289.

Comentario del experto

La exploración clínica nos puede dar una información tan importante que nos permite hacer el diagnóstico diferencial en el vértigo agudo con más sensibilidad que otras pruebas y evitar los errores diagnósticos. Evaluar la situación vestibular del paciente mediante el reflejo oculovestibular, la alineación de los ojos y la presencia de nistagmus dentro de una adecuada exploración neurológica puede ser fundamental en estos casos.

Dr. Jesús Porta Etessam
Servicio de Neurología.
Hospital Clínico Universitario San Carlos. Madrid