Ophthalmology and ENT — Dizziness, Vertigo and the Neck Lump, NMC MBBS licence examination syllabus (Nepal Medical Council).
Dizziness, Vertigo and the Neck Lump
The most useful test in a dizzy patient costs nothing: ask them to walk.
Two common presentations, both of which are usually benign and occasionally serious, and both of which are sorted by a small number of questions rather than by investigation.
"Dizzy" is four symptoms sharing one word
Before anything else, establish what the patient actually means. The word covers four different symptoms with different causes, and treating them as one condition sends the assessment in the wrong direction.
Vertigo — an illusion of movement. The room spins, or the patient feels they are moving when still. This points to the vestibular system or its central connections.
Presyncope — the feeling of being about to faint. This is a cardiovascular symptom: postural drop, arrhythmia, anaemia, bleeding, dehydration.
Disequilibrium — unsteadiness on the feet without any spinning sensation, typically worse in the dark. Neurological, visual or musculoskeletal.
Light-headedness — vague and often without a clear organic cause, with anxiety and hyperventilation frequently contributing.
The practical technique: ask the patient to describe the sensation without using the word "dizzy". That single instruction separates the four more reliably than any list of follow-up questions, because it forces a description rather than a label — and a patient who says "the room went round" has told you something a patient who says "I felt like I was going to drop" has not.
Vertigo: duration and hearing sort most of it
For genuine vertigo, two questions narrow the peripheral causes considerably: how long does an attack last, and is the hearing affected.
Brief attacks triggered by head position — rolling over in bed, lying down, looking up — that settle when the patient keeps still, with normal hearing. This is the pattern of benign positional vertigo, and the positional trigger is the diagnostic feature.
Longer episodes with hearing loss, tinnitus and a sense of fullness in the ear, where the hearing fluctuates between attacks.
A single prolonged attack lasting days, often following a viral illness, severe at first and then gradually settling as the brain compensates.
No durations in minutes or hours are given here deliberately. They overlap between conditions far more than textbook summaries suggest, and a patient whose attack falls outside a memorised range should not be reclassified because of it.
The question that actually matters
The clinical task is not naming the peripheral cause. It is separating peripheral vertigo from a posterior circulation stroke, which can present with vertigo alone.
Features pointing central:
Inability to walk unaided — the single most useful sign.
Other neurological features — double vision, slurred speech, swallowing difficulty, facial or limb weakness or numbness.
New severe headache, particularly at the back of the head.
A first attack in an older patient with vascular risk factors.
The trap is that severity does not discriminate. Peripheral vertigo is frequently the more dramatic presentation — the patient vomits, cannot open their eyes, and appears profoundly unwell — while a posterior circulation stroke may look comparatively unimpressive. Judging by how ill the patient looks gets this backwards.
💡 Which is why the walking test earns its place: a patient with peripheral vertigo staggers but can usually walk if supported; a patient with a central lesion often cannot stand at all. It costs nothing, needs no equipment, and discriminates better than the impression the patient gives lying on a trolley. If they cannot walk, treat it as central until proven otherwise.
The neck lump
Neck lumps are common, and the assessment turns on age and duration before anything else.
In a child, a short history of a tender lump alongside an infection is almost always a reactive lymph node. It is extremely common, and it settles as the infection settles.
In an adult, a persistent, painless, hard or fixed lump is malignancy until proven otherwise. The features that raise concern are the same ones that indicate invasion elsewhere in the body — fixity means the lump is attached to surrounding structures rather than sitting within them.
The point that changes the examination: a neck node can be the first presentation of a head and neck cancer whose primary is in the mouth, tongue base, tonsil, nose or larynx. So a persistent neck lump in an adult requires you to look in the mouth and throat and ask about tobacco, betel quid and alcohol — the risk factors set out in the ENT chapter. Examining only the lump misses the disease.
Persistent nodes also raise tuberculosis, which is an important cause in Nepal, and lymphoma, particularly with fever, weight loss or night sweats.
What not to do with it
Do not excise a neck lump simply to find out what it is. This is a genuine trap, because it feels like decisive management.
If the node is malignant, an open biopsy disturbs tissue planes and can compromise the definitive operation that follows — potentially worsening the outcome for a patient whose disease was curable. The correct sequence is to find the primary first, examine the sites it could have come from, and use needle sampling rather than open surgery for tissue diagnosis where required.
Two movements localise a midline lump and are worth knowing because they take seconds:
A lump that moves on swallowing is attached to the larynx and trachea — thyroid.
A lump that moves on tongue protrusion is a thyroglossal cyst, tethered along its embryological tract.
Two further things
Tinnitus that is unilateral or pulsatile is different. Bilateral tinnitus with symmetrical hearing loss is common and usually benign. Tinnitus in one ear only, or that beats in time with the pulse, needs explaining rather than reassuring — the same principle as unilateral hearing loss in the ENT chapter.
A dizzy elderly patient may be describing their medication. Antihypertensives, sedatives, antidepressants and anticholinergics all cause dizziness, and polypharmacy compounds it. A medication review is often more productive than a vestibular assessment, and this connects directly to the falls and polypharmacy chapter.
Putting it together
Ask them to describe it without the word "dizzy" — vertigo, presyncope, disequilibrium and light-headedness have different causes.
Duration and hearing sort the peripheral vertigos; positional triggering with normal hearing is the commonest pattern.
Severity does not discriminate central from peripheral — peripheral is often more dramatic.
Ask them to walk. Inability to walk unaided means central until proven otherwise.
A persistent painless neck lump in an adult is malignancy until proven otherwise — and look in the mouth.
Do not excise it to find out. Find the primary, sample with a needle.
No manoeuvre technique, attack durations, node sizes or drug doses appear here: manoeuvres performed unsupervised can harm, durations overlap between conditions, and size is a poor discriminator. Use your local protocol.
Syllabus points
Four symptoms sharing the word 'dizzy'
Describe it without using the word
Duration and hearing sort peripheral vertigo
Severity does not discriminate central from peripheral
Ask them to walk
Neck lump — age, duration, fixity
Look in the mouth; do not excise to diagnose
Swallowing vs tongue protrusion; unilateral tinnitus
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