Should a 66-year-old female with dizziness be referred to an Ear, Nose, and Throat (ENT) specialist or a neurologist first?

Referral for Dizziness in a 66-Year-Old Female

A 66-year-old female with dizziness should initially be referred to an ENT specialist, as the majority of dizziness cases are related to vestibular disorders that fall within ENT expertise. 1

Initial Evaluation Decision Algorithm

1. First-line referral: ENT specialist

   • Vestibular disorders account for the majority of dizziness cases
   • ENT specialists are equipped to perform critical diagnostic tests:
     • Dix-Hallpike maneuver for BPPV
     • Assessment for nystagmus
     • Evaluation of hearing loss and tinnitus
   • Can diagnose and treat common causes like:
     • Benign Paroxysmal Positional Vertigo (BPPV)
     • Ménière's disease
     • Vestibular neuritis
     • Labyrinthitis

2. When to refer to Neurology instead:

   • Presence of focal neurological deficits
   • Abnormal HINTS examination
   • Severe headache accompanying vertigo
   • Vertigo with visual blurring and other neurological symptoms
   • Failed response to ENT treatment
   • Suspicion of stroke or other central nervous system disorders

Clinical Reasoning

The American Academy of Otolaryngology-Head and Neck Surgery guidelines support ENT as first-line specialists because:

• The most common causes of vertigo are peripheral vestibular disorders:

  • BPPV (characterized by brief vertigo with position changes)
  • Ménière's disease (episodes lasting 20 minutes to 24 hours with hearing symptoms)
  • Vestibular neuritis (sudden severe vertigo with prolonged nausea) 1

• ENT specialists can immediately perform diagnostic maneuvers like the Dix-Hallpike test and implement treatments like the Epley maneuver, which has an 80% success rate for BPPV 1, 2

• Many cases can be diagnosed and treated in a single visit with an ENT specialist 2

Important Considerations

• While stroke can present with dizziness (accounting for approximately 20% of emergency room dizziness cases), most cases in outpatient settings are benign peripheral vestibular disorders 3

• The clinical presentation helps distinguish between peripheral and central causes:

  • Peripheral: Often positional, brief episodes, may have hearing symptoms
  • Central: More likely to have accompanying neurological symptoms, visual disturbances 1

• A structured approach focusing on timing, triggers, and associated symptoms is recommended by the American Geriatrics Society 1

• If ENT evaluation doesn't yield a diagnosis or treatment is unsuccessful, subsequent referral to neurology is appropriate 4

Common Pitfalls to Avoid

• Focusing on the quality of dizziness rather than timing and triggers 1
• Failing to perform the Dix-Hallpike maneuver in patients with positional vertigo 1
• Routinely prescribing vestibular suppressants for BPPV 1
• Missing central causes of vertigo by not performing the HINTS examination 1
• Ordering unnecessary imaging studies in patients with clear peripheral vertigo 1

By starting with an ENT referral, the patient will receive appropriate evaluation for the most common causes of dizziness while maintaining the option for neurological referral if needed based on findings or treatment response.