Who should a patient with balance concerns be referred to?

Who Should Receive Referrals for Balance Concerns

Patients with balance concerns should be referred to a clinician who can differentiate BPPV from other causes of imbalance, dizziness, and vertigo—typically an otolaryngologist (ENT), neurologist, or specialized balance clinic, depending on the clinical presentation and suspected etiology. 1

Initial Diagnostic Approach

The referring clinician should first attempt to categorize the balance disorder through targeted history:

• Ask three screening questions: "Have you fallen in the past year?", "Do you feel unsteady when standing or walking?", and "Are you worried about falling?" A "yes" to any requires formal balance testing 2
• Distinguish true vertigo from nonspecific dizziness: True vertigo (spinning sensation) suggests vestibular pathology, while vague lightheadedness often indicates multifactorial causes 3
• Perform Dix-Hallpike maneuver for suspected posterior canal BPPV and supine roll test if Dix-Hallpike is negative but history suggests BPPV 1

Referral Pathways by Clinical Presentation

Refer to Otolaryngology (ENT) when:

• Benign Paroxysmal Positional Vertigo (BPPV) is diagnosed or suspected but the clinician cannot perform canalith repositioning procedures 1
• Lateral semicircular canal BPPV requires specialized assessment with supine roll testing 1
• Treatment failure after initial repositioning attempts or persistent symptoms beyond 1 month 1
• Atypical symptoms including subjective hearing loss, tinnitus, aural fullness, or nonpositional vertigo that may indicate Ménière's disease or other peripheral vestibular disorders 1, 4

Refer to Neurology or Neuro-otology when:

• Central nervous system signs are present: internuclear ophthalmoplegia, nystagmus patterns inconsistent with peripheral vestibular disease, ataxia, hemiparesis, sensory loss, or Horner's syndrome 1
• Skew deviation is suspected (vertical diplopia with head tilt, especially with neurological symptoms) 1
• Acute vestibular syndrome with concern for stroke—though bedside head impulse testing can help differentiate vestibular neuritis from stroke 4
• Episodic spontaneous vertigo lasting minutes to hours that may represent vestibular migraine or requires differentiation from Ménière's disease 4

Refer to Physical Therapy/Vestibular Rehabilitation when:

• Vestibular rehabilitation is indicated as adjunctive or primary treatment 1
• Bilateral vestibular loss causes ataxia and oscillopsia rather than vertigo 4
• Impaired mobility or balance requires gait training and fall prevention strategies 1

Consider Multidisciplinary Balance Clinic when available:

• Complex or undiagnosed cases benefit from consultant-led teams involving otologists, audiologists, and neurophysiotherapists, which achieve 97% definitive diagnosis rates versus 64% in general clinics 5

Modifying Factors Requiring Urgent Referral

Assess for factors that necessitate expedited evaluation 1:

• Impaired mobility or high fall risk (Timed Up and Go >12 seconds, Berg Balance Scale <41) 2
• Central nervous system disorders suggesting stroke or mass lesion 1
• Lack of home support making outpatient management unsafe 1
• Rapid clinical deterioration or subdural hematoma with mass effect (requires emergency neurosurgical referral) 1

Common Pitfalls to Avoid

• Do not routinely order imaging or vestibular testing for patients meeting BPPV diagnostic criteria without additional inconsistent signs or symptoms 1
• Do not prescribe vestibular suppressants (antihistamines, benzodiazepines) as routine treatment for BPPV 1
• Do not miss lateral canal BPPV by failing to perform supine roll test when Dix-Hallpike is negative but history is compatible 1
• Counsel patients about fall risk at initial diagnosis, particularly elderly and frail patients who are vulnerable between diagnosis and definitive treatment 1

Reassessment Timeline

Reassess within 1 month after initial observation or treatment to document resolution or identify treatment failure requiring specialist evaluation for unresolved BPPV or underlying peripheral vestibular/CNS disorders 1