GGC - Primary Care
In cases of acute onset, severe dizziness, stroke should be excluded in the first instance. Specifics of the management of stroke is outwith the remit of ENT - please see neurology guidance.
Acute onset, severe
Warning
Background:
The majority of patients who describe ‘dizziness’ or balance upset do NOT have a disease of the inner ear and do NOT require specialist ENT input. Dizziness can come from neurological, cardiac or otological causes. Otological causes are generally self-limiting but may require exclusion of a stroke.
Vestibular Neuronitis is presumed to be due to inflammation / disorder of the vestibular nerve. It is defined by sudden rotational vertigo lasting approximately 2 weeks with no other associated symptoms. Patients are often worst for the first week and then slowly improve. Relapses can occur but are not common. CVA should be excluded in this patient, ENT are not involved with CVA assessment pathway. Avoid use of vestibular sedatives beyond first week as these can impair central compensation and result in chronic balance upset. Vestibular rehabilitation exercises are key to preventing chronic imbalance.
Labyrinthitis is a sudden failure of an inner ear. It can occur as an infective complication of acute otitis media or meningitis. It is defined by sudden rotational vertigo lasting approximately 2 weeks with associated unilateral hearing loss. The patients balance improves as central compensation occurs for the vestibular loss. CVA should be excluded as a cause. Avoid use of vestibular sedatives beyond first week as these can impair central compensation and result in chronic balance upset. Vestibular rehabilitation exercises are key to preventing chronic imbalance.
Vestibular Migraine can occur in anyone but more common in those with a history of migraine. It is categorised as episodic rotational vertigo with or without aura / headache. Examination is normally unremarkable. This condition is out with the remit of ENT and should be managed as per migraine.
How to assess:
A comprehensive history is likely to yield the diagnosis
Cardiovascular examination including lying/standing BP
Full neurological examination
Ear examination
How to manage:
CVA must be excluded in patients presenting with sudden rotational vertigo. It is estimated that in 3% of patients presenting with sudden rotational vertigo symptoms are due to a posterior circulatory stroke. CT imaging can miss signs in this patient group in 50% of cases. Referrals will be returned to primary / secondary care if there is a risk of CVA and it has not been excluded.
Vestibular rehabilitation exercises (Cawthorne-Cooksey exercises) are key to preventing chronic imbalance following an episode of vestibular neuronitis / acute labyrinthitis
Vestibular migraine is a common cause of dizziness. This is far more common than Meniere's disease and many symptoms overlap. In those with a history of migraines or headaches associated with their vertigo episodes, vestibular migraine is the most likely cause of their dizziness and treatment should be commenced as per neurology guidelines. Please see the the Barany Society diagnostic criteria.