Evaluation of dizziness in the emergency department: prevalence and diagnostic utility of clinical scales for functional vertigo

Abstract

Introduction: Functional vertigo is commonly missed in the emergency department (ED) and often misdiagnosed as other peripheral vestibular disorders. It is strongly associated with anxiety and depression, yet standardized diagnostic criteria are lacking in the ED setting, leading to unnecessary tests and misdiagnosis. We aimed to assess the diagnostic accuracy of the Vertigo Symptom Scale-Short Form-Autonomic (VSS-SF-A) and the Hospital Anxiety and Depression Scale-Anxiety (HADS-A) and-Depression (HADS-D) for distinguishing functional vertigo from other peripheral vertigos in the ED and to determine its prevalence. Methods: This was a prospective, cross-sectional, observational studey of adult patients of a tertiary-care ED with dizziness.. We included patients who received an initial peripheral vertigo diagnosis from attending emergency physicians. Blinded otolaryngologists (ENT) verified all final diagnoses through standardized evaluation methods performed on the same day as the ED visit. We excluded patients with central, metabolic, cardiovascular conditions. Study participants received thorough vestibular evaluations while a separate physician, also blinded to diagnostic outcomes, administered the VSS and HADS tests, which typically require 15-20 minutes to complete. The final ENT evaluation served as the criterion reference for the diagnosis of functional vertigo. We evaluated the diagnostic accuracy of the scales through receiver operating characteristic (ROC) analysis. Results: During the study period, 694 patients presented to the ED with dizziness-related complaints, of whom 69 (9.9%) met the inclusion criteria and were enrolled in the study. Of 69 patients initially diagnosed with peripheral vertigo in the ED, ENT specialists confirmed functional vertigo in 25 (36.2%) and peripheral vertigo in 44 (63.8%). Functional vertigo patients were significantly younger (43.4 t 16.9 vs 60.1 t 14.9 years of age, P < .001). In patients with functional vertigo, the mean VSS-SF-A, HADS-A, and HADS-D scores were 9.04, 9.28, and 7.52, respectively, compared to 3.80, 4.18, and 2.91 in peripheral vertigo cases. Conversely, the VSS-SF subscale-Vestibular-Balance (VSS-SF-V)-scores were higher in peripheral vertigo patients (13.05 vs 6.56), all P < .001. The ROC analysis showed that VSS-SF-A (cutoff >= 8, area under the curve [AUC] 0.85, 95% CI, 0.76-0.94) had the highest accuracy for diagnosing functional vertigo, with a sensitivity of 72% and specificity of 84.1%, followed by the HADS-A (cutoff >= 8, AUC = 0.81, 95% CI, 0.70-0.91), which had a sensitivity of 68% and specificity of 88.6%, while HADS-D (cutoff >= 4, AUC = 0.80 95% CI, 0.60-0.90) showed 76% sensitivity and 75% specificity. Conclusion: Functional vertigo is an underdiagnosed condition that produces dizziness in patients. The Vertigo Symptom Scale and Hospital Anxiety and Depression Scale show promise for enhancing early diagnosis while reducing unnecessary imaging and improving patient care. Future research is needed to confirm these findings through larger multicenter cohorts.