From the Guidelines
A patient with vertigo should be referred to an ENT specialist when symptoms persist despite initial treatment, when vertigo is severe or recurrent, or when there are concerning associated symptoms, as indicated by the clinical practice guideline for Meniere's disease 1. The decision to refer a patient with vertigo to an ENT specialist should be based on the severity and duration of symptoms, as well as the presence of associated symptoms such as hearing loss, tinnitus, or ear fullness.
- Referral is appropriate if vertigo continues beyond 2-4 weeks of primary care management,
- if it's accompanied by hearing loss, tinnitus, ear fullness, or ear pain,
- or if there are signs of a central nervous system disorder such as slurred speech, double vision, or weakness. Patients with sudden onset severe vertigo that significantly impacts daily functioning should also be referred promptly. Additionally, referral is warranted when the diagnosis is unclear or when conditions like Meniere's disease, vestibular neuritis, or acoustic neuroma are suspected, as outlined in the clinical practice guideline for Meniere's disease 1. ENT specialists can perform specialized tests like videonystagmography, rotary chair testing, and vestibular evoked myogenic potentials that aren't available in primary care settings, and provide advanced treatments including vestibular rehabilitation therapy, particle repositioning maneuvers for BPPV, medication adjustments, and surgical interventions when necessary, as discussed in the guideline for Meniere's disease 1. Early referral is important because proper diagnosis and treatment can significantly improve quality of life and prevent complications from chronic vertigo. The goals of treatment for Meniere's disease are to prevent or reduce the severity and frequency of vertigo attacks, relieve or prevent hearing loss, tinnitus, and aural fullness, and improve overall quality of life, as stated in the clinical practice guideline for Meniere's disease 1.
From the Research
Referral to ENT Specialist for Vertigo
- A patient with vertigo should be referred to an Ear, Nose, and Throat (ENT) specialist in the following situations:
- Vertigo with unilateral hearing loss, which may suggest Meniere disease 2
- Episodic vertigo not associated with any trigger, which may be a symptom of vestibular neuritis 2
- Vertigo with tinnitus, which may be related to benign paroxysmal positional vertigo (BPPV) or other vestibular disorders 3
- Vertigo with painful disorders related to the ear, such as temporomandibular dysfunction or myofacial painful syndrome 4
- The ENT specialist can perform a thorough evaluation, including a physical examination, laboratory testing, and imaging studies, to determine the underlying cause of vertigo 5
- The HINTS (head-impulse, nystagmus, test of skew) examination can help distinguish peripheral from central etiologies of vertigo, and guide further management 2
Timing of Referral
- Referral to an ENT specialist should be considered when:
- Vertigo is severe or persistent, and does not respond to initial treatment 2
- There are associated symptoms, such as hearing loss, tinnitus, or painful disorders related to the ear 5, 3, 4
- The patient has a history of head trauma, ear surgery, or other conditions that may increase the risk of vestibular disorders 6