Dizziness and Vertigo

Overview

ENT Clinics are currently under extreme pressure as a result of COVID recovery and increased demand for appointments.

Please consider using primary care management pathways where possible and only refer patients if these options have been exhausted. When referring, please also warn patients of long waits for outpatient appointments. The ENT service kindly requests that if patients approach referrers requesting an appointment to be expedited not to ask them to ring the hospital as they will not be able to help. Only submit written requests to expedite if there is clinical deterioration or concern. Do not submit another eRS referral in this situation as these requests will be returned.

Current waits for outpatient clinics in ENT are as follows (January 2024)

• Otology- 8 months
• Rhinology- 6 months
• Head and Neck- 5 months
• Direct Access Vertigo - 12 months

Vertigo or Dizziness

People with vertigo usually describe rotatory or spinning symptoms. To determine that the person has vertigo rather than non-rotatory dizziness (for example presyncope, disequilibrium, or light-headedness) ask in detail about their symptoms (1).

• Consider asking: 'When you have dizzy spells, do you feel light-headed or do you see the world spin around you as if you had just got off a playground roundabout?'
• If the person has nystagmus it is likely that their dizziness is vertigo. 

The following page primarily focuses on the diagnosis and management of vertigo but also describes some other causes of dizziness. 

Driving advice

Patients with attacks of severe vertigo (what ever the cause) should consider whether they are safe to continue driving. As with other driving advice, patients should contact DVLA. Patients who drive buses, coaches or lorries will need more detailed advice. Guidelines say that patients who experience severe dizziness without sufficient warning to maintain control of the car / motorbike should avoid driving. https://www.gov.uk/dizziness-and-driving

Who to Refer

Most causes of vertigo without red flags can be managed in primary care. Please see common causes and advice in the Management in Primary care section below.

To guide diagnosis and appropriate management, please see the following flow diagrams based on either a single, or multiple episodes of vertigo. These have been put together with Steve Broomfield, ENT consultant at UHBW with interest in vertigo and dizziness. 

• Single acute episode of vertigo
• Multiple episodes of vertigo

Red Flags

Central Vertigo

Patients with acute onset of vertigo with a suspected central cause should be admitted to hospital to rule out cerebellar or brain stem stroke.

Features increasing suspicion of a central cause of vertigo include:

• Prolonged, severe vertigo (although this can also indicate vestibular neuronitis or Meniere's disease). 
• New-onset headache or recent trauma.
• Cardiovascular risk factors.

Further information on diffentiating between central and peripheral vertigo can be found in Clinical Knowledge Summaries - How should I determine the cause of vertigo. 

Acute sensorineural hearing loss

If vertigo is associated with sensorineural hearing loss and/or tinnitus then the patient requires urgent assessment. If this is suspected then refer to the ENT HOT clinic which is available via eRS. You may also like to discuss with the on call ENT team as sometimes high dose steroids are also advised in these cases while the patient is awaiting assessment.

Acute Otitis Media with vertigo

If vertigo is sudden onset in a patient with acute otitis media this may suggest acute bacterial labyrinthitis. This is a rare condition, but if suspected please refer to ENT On call. 

Management in Primary Care

Most causes of vertigo without red flags can be managed in primary care. Please see common causes and advice on their management below:

Labyrinthitis and Vestibular Neuritis

Patients with peripheral vestibular disorders such as labyrinthitis or vestibular neuritis typically experience an acute episode of very severe dizziness for 24-72 hours, accompanied by nausea or vomiting.  True vertigo (usually rotatory) lasts for seconds or minutes with head movement.  Symptomology reduces the central compensation over a period of days and weeks, though this may be incomplete.  Following the acute phase, treatment with gaze and balance exercises have reported high success rates with improving central compensation.  These exercises are known as 'vestibular rehabilitation' (VR).  Some patients will benefit from both VR and repositioning techniques. Patients presenting with stable, peripheral vestibular deficit frequently benefit from physical manoeuvres or exercises, and may not necessarily warrant referral to ENT in the first instance.

Benign Paroxysmal Positional Vertigo

One of the most common forms is benign paroxysmal positional vertigo (BPPV), due to movement of calcium carbonate crystals in the semicircular canals.  Patients usually describe true vertigo (illusion of movement) or dizziness with movements such as turning over in bed, or head and neck movements.  Symptoms usually last for a few seconds or up to one minute.  Treatment involves a manoeuvre (such as the canalith repositioning technique or Epley) to move the debris to an appropriate part of the vestibular system.  This is very effective for the majority of patients and can be performed in primary care. Patients can also try using Brandt-Daroff exercises (2) at home.

See links below to BMJ videos on YouTube: 

• Dix-Hallpike video
• Epley Manoeuvre video
• Brandt-Daroff video

There is also a quick reference guide for the Epley manoeuvre.

Vestibular migraine

This is a very common diagnosis and can often be managed in primary care.  It is less well recognised than it should be, especially when other migraine symptoms aren't prominent. 

Please see further information on diagnosis and management on the Migraine Trust website.

For further advice on management of migraine please also see the Remedy Headache page. You may also like to direct patients to self-help advice.

Meniere's Disease

Meniere's disease is a rare progressive disorder of the inner ear of unknown cause characterized by recurrent acute episodes of vertigo, hearing loss, tinnitus, and a sense of pressure in the ear (aural fullness). Vertigo (causing dizziness, nausea, and vomiting) is often the most prominent symptom.

Other Causes of Dizziness and Vertigo

In addition Clinical Knowledge Summaries have useful advice on management of BPPV and other causes of vertigo.

Functional Dizziness

Functional dizziness is also known as Persistent Postural Perceptual Dizziness (PPPD), chronic subjective dizziness or visual vertigo. Patients often present with persistent / constant dizziness. This may not be true vertigo although it may have started with a vertigo attack.

Symptoms often include dissociative symptoms eg. feeling spaced out / separated from the body / floating, etc

Symptoms also often include "visual vertigo" ie. dislike of busy visual environment eg. computer screens, supermarkets, etc

There may be an overlap with vestibular migraine and there is often an element of anxiety

Treatment consists of a clear explanation, reassurance and excluding other causes:

• physiotherapy
• medication (migraine +/- anxiety treatment as indicated)
• psychological treatments (eg.CBT) may be helpful

For more information refer to dizziness section of website Neurosymptoms.org

Psychiatric causes and Hyperventilation Syndrome

Consider psychiatric causes including hyperventilation syndrome

• light-headedness may be related to:
  • anxiety disorders
  • depressive disorders
• hyperventilation: may be peri-oral paraesthesia (sensation of numbness around the mouth) and digital paraesthesia
  • consider using the Nijmegen questionnaire
• provide information on control of breathing - see patient leaflets
• HVS leaflet
• HVS good breathing

both available from http://www.physiohypervent.org/

Respiratory Physiotherapy at UHBW also see patients with confirmed dysfunctional breathing pattern (hyperventilation)

Vertebrobasilar Insufficiency

The term 'vertebrobasilar insufficiency (VBI)' is an old one and poorly defined. It is best thought of as a collection of conditions rather than one diagnosis. See the article Vertebrobasilar Insufficiency | Doctor (4) for further information.

The brain has four main arteries which often allow for collateral blood supply should there be an obstruction. However, in cases of critical blockage of a blood vessel, or atherosclerosis in multiple vessels, symptoms can occur.  The commonest cause is thromboembolic disease and there will usually be a history of cardiovascular risk factors and neurological symptoms to suggest a TIA/stroke. Vertigo is common but is rarely the only symptom.

VBI caused by compression of a vessel from turning the head is rare, and vertigo in this situation is also usually accompanied by other symptoms (visual symptoms, altered speech, motor/sensory weakness, reduced co-ordination/ataxia, headache). Isolated vertigo/dizziness with neck movement is nearly always due to BPPV (3). If there are other presenting neurological symptoms then TIA or stroke should be considered (4).

Referral

Referral should be considered where a patient's symptoms are more severe or debilitating and are not responding to measures described above.

All referrals go via the ENT otology at UHBW on eRS where they will be triaged to one of the services below (see their website page for more details - includes details of their private vestibular service):

1. The Direct Access Vertigo Clinic:
This is a direct access clinic that allows for the complete assessment and treatment of patients with a clear peripheral (i.e. inner ear) cause for their symptoms. The clinic is run by audiological scientists with input from an ENT consultant where necessary. Any patient presenting with isolated rotatory vertigo brought on by, or worse with, movement can be referred directly to the balance clinic. This includes:

Benign Paroxysmal Positional Vertigo (BPPV). Typically this is rotatory vertigo lasting 30 – 60 seconds with movements e.g. turning over in bed. Repositioning movements are often effective.

Acute Vestibular Failure (Labyrinthitis). This is acute onset severe vertigo, often with nausea and vomiting, that can last 48-72 hours. Most patients will then compensate over several weeks, and return to normal balance function. Those that do not improve may benefit from targeted vestibular rehabilitation.
Other rotatory vertigo where the diagnosis is unclear but there are no other otological or medical symptoms (see below).

2. The ENT Balance Clinic
This is the default option for patients with balance disorders and is most appropriate for those with vertigo in conjunction with asymmetric or sudden hearing loss, tinnitus, otalgia, otorrhoea, or significant medical co-morbidities. This includes patients with suspected Meniere’s disease or vestibular migraine.

Where migraine is the clear/ most likely diagnosis, referral to neurology or for neurology A and G (both via eRS) can also be considered if the patient has not responded to appropriate migraine treatment in primary care - See the Headache page for details.

3. The Complex Balance Clinic
This is a multi-disciplinary clinic with an ENT consultant and clinical scientist working together. Patients are referred into this clinic from either the direct access vertigo clinic or the ENT clinic (or following triage of the initial referral). The complex balance clinic is reserved for those with more complicated balance problems e.g. where the diagnosis is unclear, initial treatment has been unsuccessful, or there is a particularly complicated history. Children with imbalance may also be seen in this clinic.

Please note that cardiology/ neurology referral should be considered for patients with primarily cardiovascular or neurological symptoms.

Referrals are for more complex problems and are therefore triaged by either the direct access vertigo clinic or ENT balance clinic above. This is therefore not available on eReferral.

Resources

(1) Vertigo - Clinical Knowledge Summaries

(2) Brandt-Daroff exercises for BPPV

(3) Advice for management of migraine in primary care (nhslothian.scot)

(4) Vertebrobasilar Insufficiency | Doctor (patient.info)

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