Is an Ear, Nose, and Throat (ENT) specialist a good referral for patients with vertigo?

ENT Referral for Vertigo: When and Why

ENT specialists are appropriate primary referrals for patients with vertigo, particularly when symptoms suggest peripheral vestibular disorders such as Ménière's disease, benign paroxysmal positional vertigo (BPPV), or vestibular neuritis. 1, 2

Distinguishing Peripheral vs. Central Vertigo

When evaluating a patient with vertigo, the first critical step is determining whether the cause is peripheral (inner ear) or central (brainstem/cerebellum):

Peripheral Vertigo (ENT-appropriate)

• Characterized by:
  • Rotational vertigo with sudden onset
  • Associated hearing loss, tinnitus, or aural fullness
  • Symptoms provoked by position changes
  • Nausea and vomiting
  • Nystagmus that suppresses with visual fixation
  • Normal neurological exam

Central Vertigo (Neurology-appropriate)

• Characterized by:
  • Gradual onset vertigo
  • Persistent symptoms (>24 hours)
  • Associated neurological symptoms (diplopia, dysarthria, ataxia)
  • Nystagmus that doesn't suppress with fixation
  • Abnormal neurological exam

Common Peripheral Vestibular Disorders for ENT Referral

1. Benign Paroxysmal Positional Vertigo (BPPV)

   • Brief episodes (<1 minute) triggered by head position changes
   • No associated hearing loss or tinnitus
   • Diagnosed with Dix-Hallpike maneuver
   • Treatment: Canalith repositioning procedures (Epley maneuver)

2. Ménière's Disease

   • Episodic vertigo lasting hours
   • Associated fluctuating hearing loss, tinnitus, aural fullness
   • Treatment: Lifestyle modifications, medications, procedures

3. Vestibular Neuritis

   • Sudden, severe vertigo lasting days
   • No hearing loss
   • Treatment: Vestibular suppressants acutely, vestibular rehabilitation

Diagnostic Approach by ENT

ENT specialists are equipped to:

• Perform specialized vestibular testing
• Conduct audiometric evaluation
• Perform the Dix-Hallpike maneuver and supine roll test for BPPV
• Administer canalith repositioning procedures
• Order appropriate imaging when needed 1

Imaging Considerations

According to the American College of Radiology Appropriateness Criteria 1:

• Peripheral vertigo: CT temporal bone without contrast OR MRI head/internal auditory canal without/with contrast
• Central vertigo: MRI head/internal auditory canal without/with contrast is preferred

Evidence for ENT-Led Vestibular Clinics

Recent research shows substantial agreement between ENT specialists and specialized vestibular physiotherapists in diagnosing and managing vestibular disorders, with agreement coefficients of 0.613 for diagnosis 3. This suggests that both ENT specialists and properly trained vestibular physiotherapists can effectively manage many vertigo cases.

Treatment Options Available Through ENT

ENT specialists can provide:

1. Canalith repositioning procedures for BPPV (90-96% success rate) 2
2. Medication management for acute symptoms:
   • Vestibular suppressants (only during acute attacks)
   • Antiemetics for nausea
   • Appropriate use of benzodiazepines for severe distress
3. Vestibular rehabilitation therapy referrals
4. Patient education on symptom management and fall prevention

When to Consider Alternative Referrals

• Neurology: When central vertigo is suspected or when neurological symptoms are present
• Cardiology: When vertigo is associated with cardiovascular symptoms
• Physical Therapy: For vestibular rehabilitation (often in conjunction with ENT management)

Pitfalls to Avoid

1. Prolonged use of vestibular suppressants - These medications impede central compensation and should only be used short-term during acute episodes 2
2. Missing central causes - Always evaluate for neurological symptoms that might suggest central pathology
3. Inadequate follow-up - Patients should be reassessed within one month to document resolution or persistence of symptoms 2

ENT referral is an appropriate and evidence-based first step for most patients presenting with vertigo, particularly when symptoms suggest a peripheral vestibular disorder. The ENT specialist can then determine if additional referrals or imaging studies are warranted based on their evaluation.