Clinical case review
Review the complete Audiology case, its five progressive clues, the diagnosis, and the clinical reasoning behind the answer.
Want to test yourself first? Play the original case before reading the clues and explanation below.
WhatsTheDx publishes a new Audiology case every day. Five clues, one diagnosis, and no account needed to play.
Play today's Audiology caseThese are the case findings in their original reveal order, moving from the broader presentation to the most discriminating evidence.
Clue 1
A 41-year-old teacher has been dizzy and unsteady on most days for seven months. Not spinning — she is careful about that word — just an unbroken sense of being slightly off, as though the floor were the deck of a boat. It has cost her a great deal: she has stopped driving, cut back to part days at work, and no longer goes into shops if she can help it.
Clue 2
There was an unmistakable beginning. Eight months ago she had several days of violent true spinning with nausea, and it settled over about a fortnight. The spinning has never returned. The unsteadiness that arrived behind it never left. It is worse every time she is upright, and it eases when she lies down.
Clue 3
Two more things reliably make it worse. Motion of any kind — walking, turning her head, riding as a passenger, an escalator — and it makes no difference which direction or which position. And busy vision: supermarket aisles are the worst place she knows, scrolling a screen sets it off, and so do patterned floors. There are no discrete attacks of spinning any more, no head position brings one on, and the dizziness never arrives with headache, light sensitivity, or sound sensitivity.
Clue 4
Everything measurable comes back clean. Physical and neurological examination is unremarkable. Pure-tone audiometry shows normal, symmetric hearing; tympanometry shows normal middle-ear function in both ears. Watch her walk and stand, though, and she does sway — visibly more when she is asked simply to stand still, and more again when the visual surround moves. She never falls, and she walks the corridor unaided.
Clue 5
Imaging is normal too. Every test has been normal — and that is not a dead end, it is the point. The workup here exists to rule other conditions out, not to rule this one in. No other disease or disorder accounts for her symptoms any better than the pattern she has been describing all along.
Diagnosis
This is persistent postural-perceptual dizziness (PPPD), the chronic functional vestibular disorder of the International Classification of Vestibular Disorders, with criteria introduced by the Bárány Society committee in 2017. All five criteria must be met, and she meets each one. Dizziness, unsteadiness, or non-spinning vertigo on most days for three months or more — hers is seven months. Symptoms worsened by upright posture, by active or passive motion without regard to direction or position, and by exposure to moving visual stimuli or complex visual patterns — standing, escalators and car journeys, supermarket aisles and patterned floors. Precipitation by a condition causing vestibular dysfunction, neurologic illness, a medical problem, or psychological distress — here the acute spinning illness eight months ago. Significant distress or functional impairment — she has stopped driving and cut back at work. And no other disease or disorder that accounts for the symptoms any better. The most instructive part of the workup is that it is normal: physical and neurological examination is generally unremarkable and imaging is normal, so testing here excludes other conditions rather than confirming this one. The one positive finding is on gait examination, where a patient may sway but often does not fall. Recognised precipitants include vestibular neuritis, benign paroxysmal positional vertigo, Meniere disease, concussion, whiplash injury, and acute psychological distress. Treatment is vestibular rehabilitation, cognitive-behavioural therapy — which decreases the maladaptive cycle of anxiety and balance control — selective serotonin reuptake inhibitors, and vestibular suppressants.
The explanation and decisive case findings were checked against the source below.
Open the clinical referenceFor education and entertainment only. This fictional case is not medical advice and does not replace supervised clinical training, diagnosis, or treatment.
