NHS Tayside RefGuide
The ENT and Audiology departments offer several clinics for the management of patients with vestibular disorders. These represent a relatively small subset of the number of conditions which might affect the balance. It is always helpful for us if we have enough information in a referral to make a decision about the appropriate clinic in which to place the referral. Patients with vestibular conditions almost always complain of the sensation of spinning at some point during the course of their illness. If there is no history at all of true vertigo then another non-vestibular condition should be considered.
Key points in the history
Relevant hearing loss, tinnitus, triggers, duration, palpitations, loss of consciousness, headache, other medical conditions, medications and neurological symptoms is essential.
BPPV
One of the most common vestibular pathologies referred is BPPV. In this case there is usually a clear positional trigger for the brief episodes and no associated hearing loss or tinnitus. A Dix-Hallpike test helps to confirm the diagnosis due to the presence of typical nystagmus. A Dix-Hallpike test allows us to vet patients to specialist audiology clinics, which may mean much earlier treatment.
Menieres and Vestibular Migraine
These conditions have a very similar presentation: Vertigo lasting hours with some associated nausea. If the patient has a history of previous migraines and denies other symptoms of Menieres, such as hearing loss or aural fullness then migraine is the likely diagnosis and should have a trial of management in the community.
Vestibular neuronitis
Has a classical presentation of vertigo lasting days with a progressive improvement over the next few weeks. Regular vestibular sedatives, such as prochlorperazine, may be helpful in the short term. If used in the longer term they may cause side effects and may also prevent patients from compensating if they have a permanent vestibular loss. Betahistine does not act as a vestibular sedative and may only be indicated in Meniere’s disease, which is rare.
Elderly patients often have multifactorial causes for their balance problems. Unless they have a very clear history typical of a vestibular problem, most commonly BPPV in this age group, then you may wish to consider a referral to the Falls clinic in MFE, rather than ENT, as a first line.