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 eg the room spins around you.

 

Why you (the SHO) 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: ‘labyrinthitis’ ie viral illness, ear infection, BPPV, Ménière’s disease, vestibular schwanomma...

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 final four peripheral causes are usually dealt with by ENT surgeons.

  • Uncomplicated ear infections do not require admission of the patient and the dizziness will improve with treatment
  • BPPV is unpleasant but the vertigo lasts seconds and can be effectively dealt with as an outpatient
  • Ménière’s attacks typically last a few hours and sufferers have strategies to deal with them
  • Vestibular schwannomas can rarely bleed into themselves - get an MRI internal auditory meatus 

 

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 regular cinnarizine and/or cyclizine) 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.

 

 

Page last reviewed: 23 September 2016