A 55-year-old African American woman presented with a chief complaint of dizziness to the otolaryngology clinic. She had been referred by a neurologist. The patient had a myocardial infarction (MI) 1 year previously, and since that time experienced constant, persistent dizziness with episodic bouts of “room-spinning” vertigo. She described her constant dizziness as “just dizzy all day, every day,” but said that positional changes, such as bending over or standing up too quickly, made it worse. The episodes of vertigo were preceded by a flulike prodrome consisting of diaphoresis, nausea, and numbness and tingling in her hands and feet. In 2 instances, she stated that she briefly lost consciousness. These episodes typically occurred twice per month, lasting from 5 minutes to a few hours, and were relieved by intravenous diazepam in the emergency department on at least 1 occasion. Meclizine was ineffective. The patient denied associated chest pain, palpitations, dyspnea, headaches, hearing loss, tinnitus, otalgia, aural pressure, or facial weakness. Findings from previous workups from a cardiologist and a neurologist were unremarkable, including normal orthostatic measurements, normal findings on Dix-Hallpike testing, and a normal magnetic resonance image of the brain.
In addition to her MI and subsequent percutaneous coronary intervention with the placement of 2 stents, the patient's medical history was notable for multiple ear infections as a child and posttraumatic stress disorder (PTSD). Her medications included 81 mg of aspirin once daily, 40 mg of atorvastatin once daily, 75 mg of clopidogrel once daily, 5 mg of escitalopram once daily, 500 mg of ranolazine twice daily, and 20 mg of trospium twice daily. She lived alone and had to stop working because of her persistent symptoms.
Physical examination revealed the patient to be alert and oriented, with normal mood and cognition. The HEENT (head, eyes, ears, nose, and throat) examination demonstrated that the head was normocephalic and atraumatic. Pupils were equal, round, and reactive to light. Eye movements were normal without evidence of nystagmus. External auditory canals were patent and clear of debris. Tympanic membranes were intact, mobile, and without middle effusion. Nose and throat examination findings were also normal. A neurologic examination revealed that cranial nerves II to XII were intact bilaterally. There was no evidence of dysarthria or short- or long-term memory deficits. Muscle tone was normal in all muscle groups, strength was +5/5 in the upper and lower extremities, and reflexes were +2/4 bilaterally. Finger-to-nose testing showed no abnormalities, no evidence of pronator drift was found, and gait was fluid and stable. On osteopathic structural examination, increased tension was noted throughout the cervical region, particularly in the upper cervical vertebrae. C3 was found to be extended, rotated, and sidebent left. The remainder of the examination findings were unremarkable. Audiogram and tympanometry results were normal. To more definitively rule out a vestibular origin, videonystagmography was used and yielded a normal result. Given these findings, our differential diagnosis included an underlying psychiatric cause (eg, PTSD, anxiety disorder, depression, or somatic symptom and related disorders), cardiac cause, or iatrogenic cause (eg, aspirin, escitalopram, ranolazine, or trospium). We informed the patient that an organic otologic cause was ruled out and suggested that she follow up with her primary care physician and to continue to follow up with her neurologist and cardiologist.