Dizziness
Some definitions
Dizziness is a broad symptom and encompassess everything from feeling off-balance after a cold through to true vertigo. Synonyms include: giddiness, lightheadedness, unsteadiness, feeling off legs, muzziness, feeling wrapped in cotton wool...
Vertigo is specifically the hallucination of movement when you are not moving in that direction. For example, you may feel that the room spins around you (rotatory vertigo) or you feel like the world is going up or down around you etc.
Why you (ENT DOCTOR OR NURSE) shouldn't admit patients with dizziness under ENT
Causes of dizziness (and/or vertigo) can be central or peripheral -
Central causes: stroke, postural hypotension, arrhythmia, transient ischaemic attack, migraine, multiple sclerosis, brain tumours, medication, alcohol, hypoglycaemia, viral illness, transient vestibular artery ischaemic attack, vertebrobasilar insufficiency, medication, sleep deprivation, sea sickness, space sickness, medication, age-related dysequilibrium …
Peripheral causes: vestibular neuronitis (called labyrinthitis if there is accompanying hearing loss), infection ie AOM or AOE, BPPV or Ménière’s disease …
Dizziness serious enough to prompt an admission to hospital is much more likely to be due to a central cause - and requires appropriate investigation by the appropriate specialty.
The peripheral causes are usually dealt with by ENT surgeons and audiologists as outpatients
Uncomplicated ear infections do not require admission of the patient and the dizziness will improve with treatment
BPPV lasts seconds and can be effectively dealt with as an outpatient
Ménière’s attacks typically last a 2-12 hours and sufferers have strategies to deal with acute attacks; they are typically already under the care of ENT and audiology
NB Vestibular schwannoma (also known as acoustic neuroma) is a rare diagnosis with an incidence of 1:100,000 per year in the UK (approximately one new schwannoma diagnosis per 16 GP practices per year). Many schwannomas do not require intervention if they are small and slow growing. Acute dizziness is rarely due to schwannomas.
That is not to say we don't care
If central and worrying causes have been ruled out, then it would be appropriate to treat the patient symptomatically (eg a limited course of regular cinnarizine and/or prochlorperazine etc.) and refer for an outpatient ENT appointment. Remember: betahistine is not a panacea for all and any vertigo; the specific indication is Ménière’s disease. In fact, a recent robust RCT showed that betahistine is no better than placebo.
If you suspect BPPV, then you should be able to test for it and treat it on the ward/in clinic. The manoeuvres are straightforward to perform: see Dix-Hallpike & Epley.
Many units have specialist dizziness clinics. In order to help the patient effectively, a clinic with balance specialists, audiology and nurse practitioner support is much better than an inpatient bedside consultation.
Do not book these patient into the daily/weekly ENT emergency clinic - frequently there is no audiology support so the patient may have to make yet another visit to hospital.
References
Lee H (2014). Isolated vascular vertigo.
Choi KD, Lee H, Kim JS (2013). Vertigo in brainstem and cerebellar strokes.
Stolte B, Holle D, Naegel S et al (2014) Vestibular migraine.
Link to ExR Virtual Reality: Dizziness
Page last reviewed: 04 May 2024