Table 2.

Use of the Physical Examination to Diagnose Patients With Acute Vestibular Syndrome

Exam Component	Peripheral (All Must Be Present to Diagnose Vestibular Neuritis)	Central (Any One of These Findings Suggests Posterior Fossa Stroke)
Nystagmus (straight-ahead gaze and rightward and leftward gaze)	Dominantly horizontal, direction-fixed, beating away from the affected side*	Dominantly vertical or torsional or dominantly horizontal, direction-changing on left/right gaze†
Test of Skew (alternate cover test)	Normal vertical eye alignment and no corrective vertical movement (i.e., no skew deviation)	Skew deviation (small vertical correction on uncovering the eye)‡
Head Impulse Test	Unilaterally abnormal with head moving towards the affected side (presence of a corrective re-fixation saccade towards the normal side)§	Usually bilaterally normal (no corrective saccade)
Targeted neurologic examination (see text)	No cranial nerve, brainstem, or cerebellar signs	Presence of limb ataxia, dysarthria, diplopia, ptosis, anisocoria, facial sensory loss (pain/temperature), unilateral decreased hearing
Gait and truncal ataxia	Able to walk unassisted and to sit up in stretcher without holding on or leaning against bed or rails	Unable to walk unassisted or sit up in stretcher without holding on or leaning against bed or rails

^*Inferior branch vestibular neuritis will present with downbeat-torsional nystagmus, but this is a rare disorder. From the emergency medicine perspective, vertical nystagmus in a patient with an acute vestibular syndrome patient should be considered to be central (a stroke).

^†More than half of posterior fossa strokes will have direction-fixed horizontal nystagmus that, alone, cannot be distinguished from that typically seen with vestibular neuritis.

^‡More than half of posterior fossa strokes will have no skew deviation, so, on this criterion alone, cannot be distinguished from vestibular neuritis.

^§Strokes in the anterior inferior cerebellar artery territory may produce a unilaterally abnormal head impulse test that mimics vestibular neuritis, but hearing loss is usually present as a clue. If a patient has bilaterally abnormal Head Impulse Test, this is also suspicious for a central lesion if nystagmus is present (as may be seen in Wernicke’s syndrome).