If a patient, particularly an older adult with a history of hypertension or diabetes, or a young adult with a history of ear infections, presents with dizziness, should they be referred to ENT (Ear, Nose, and Throat) or neurology for further evaluation?

Referral Decision for Dizzy Patients

For most dizzy patients, initial evaluation should be performed by the primary care provider or emergency physician using bedside testing, with ENT referral appropriate for peripheral vestibular disorders (BPPV, Meniere's disease, vestibular neuritis) and neurology referral reserved for suspected central causes with red flag features. 1, 2

Initial Categorization by Timing and Triggers

The first step is categorizing dizziness by timing and triggers rather than the patient's subjective description, as this determines the appropriate specialist 1, 2, 3:

• Brief episodic vertigo (seconds to minutes) triggered by head position changes suggests BPPV—manage with Dix-Hallpike maneuver and Epley maneuver, refer to ENT if refractory 1, 4
• Acute persistent vertigo (days to weeks) with constant symptoms requires HINTS examination to distinguish peripheral (ENT) from central (neurology) causes 1, 2
• Spontaneous episodic vertigo without positional trigger suggests vestibular migraine (neurology) or Meniere's disease (ENT) 1, 4
• Chronic dizziness (weeks to months) may indicate medication side effects, anxiety, or posterior fossa pathology requiring case-by-case specialist selection 1, 4

Critical Bedside Examination Determines Referral Path

Perform Dix-Hallpike Maneuver First

The Dix-Hallpike maneuver is the gold standard diagnostic test and should be performed in every patient with brief episodic dizziness triggered by position changes 1, 2. Positive findings (5-20 second latency, torsional upbeating nystagmus toward affected ear, symptoms resolving within 60 seconds) confirm BPPV 1, 2:

• Positive Dix-Hallpike with typical BPPV features: Treat immediately with Epley maneuver (80% success after 1-3 treatments, 90-98% with repeat maneuvers)—no imaging or specialist referral needed unless refractory 1, 4
• Atypical nystagmus patterns or failure to respond: Refer to ENT for comprehensive vestibular testing 1, 4

HINTS Examination for Acute Persistent Vertigo

For acute persistent vertigo, the HINTS examination (Head-Impulse, Nystagmus, Test of Skew) has 100% sensitivity for detecting stroke when performed by trained practitioners 1, 2:

• HINTS showing peripheral features (abnormal head impulse test, unidirectional horizontal nystagmus, no skew deviation): Likely vestibular neuritis—refer to ENT for vestibular rehabilitation 1, 4
• HINTS showing central features (normal head impulse test, direction-changing nystagmus, or skew deviation present): Urgent neurology referral and MRI brain without contrast 1, 4

Critical pitfall: 75-80% of posterior circulation strokes have no focal neurologic deficits, so normal neurologic exam does not exclude stroke 1, 4. The HINTS examination is more sensitive than early MRI (100% vs 46%) when performed by trained practitioners 4.

Red Flags Mandating Immediate Neurology Referral

Any of these features require urgent neurology consultation and MRI brain without contrast 1, 4, 2:

• Focal neurological deficits (dysarthria, diplopia, numbness, weakness)
• Sudden unilateral hearing loss
• Inability to stand or walk
• Downbeating or other central nystagmus patterns
• New severe headache accompanying dizziness
• Progressive neurologic symptoms

Associated Symptoms Guide Specialist Selection

ENT Referral Appropriate For:

• Hearing loss, tinnitus, or aural fullness: Suggests Meniere's disease—refer to ENT for audiologic examination and management with salt restriction/diuretics 1, 4, 5
• Recurrent positional vertigo: BPPV with high recurrence rate (10-18% at one year, up to 36% long-term)—ENT for ongoing management 2
• Unilateral or pulsatile tinnitus: Requires MRI head and internal auditory canal with contrast to exclude vestibular schwannoma, managed by ENT 4, 2

Neurology Referral Appropriate For:

• Headache, photophobia, phonophobia: Strongly suggests vestibular migraine—neurology for migraine prophylaxis and lifestyle modifications 1, 4
• High vascular risk patients (age >50, hypertension, diabetes, atrial fibrillation, prior stroke) with acute vestibular syndrome require neurology evaluation even with normal neurologic exam, as 11-25% may have posterior circulation stroke 4, 2
• Chronic progressive symptoms: May indicate posterior fossa mass lesion requiring neurology evaluation and MRI 1, 4

Special Considerations for Older Adults with Hypertension/Diabetes

Older adults with vascular risk factors presenting with acute persistent vertigo require MRI brain without contrast even with normal neurologic examination 4, 2:

• These patients have 11-25% risk of posterior circulation stroke despite normal exam 4
• Neurology referral is appropriate for stroke risk stratification and secondary prevention 4, 2
• However, if Dix-Hallpike is clearly positive for BPPV with typical features and no other concerning symptoms, treat with Epley maneuver without imaging or specialist referral 1, 4

Critical pitfall: Antihypertensive and cardiovascular medications are leading causes of chronic dizziness in this population—medication review is essential before specialist referral 6, 1

Young Adults with Ear Infection History

Young adults with history of ear infections presenting with dizziness should be evaluated for vestibular neuritis or labyrinthitis 1:

• Acute persistent vertigo with nausea/vomiting suggests vestibular neuritis—ENT referral for vestibular rehabilitation therapy 1, 4
• Associated hearing loss suggests labyrinthitis—ENT referral for audiologic evaluation 1
• However, if symptoms are brief and positional, perform Dix-Hallpike first as BPPV can occur as sequelae to vestibular neuritis 6, 1

Imaging Decisions Before Referral

Do not order imaging for straightforward BPPV with positive Dix-Hallpike test and no additional concerning features 1, 4, 2:

• Imaging has very low diagnostic yield (<1% for CT, 4% for MRI) in isolated dizziness 4, 2
• Ordering unnecessary imaging delays appropriate treatment 1, 4

MRI brain without contrast is indicated before neurology referral for 4, 2:

• Abnormal neurologic examination or HINTS suggesting central cause
• High vascular risk patients with acute vestibular syndrome
• Unilateral/pulsatile tinnitus or asymmetric hearing loss
• Progressive neurologic symptoms

CT head should not be used instead of MRI when stroke is suspected, as it has only 20-40% sensitivity for posterior circulation infarcts 1, 4

Common Pitfalls to Avoid

• Relying on patient's description of "spinning" versus "lightheadedness" instead of focusing on timing and triggers 1, 4, 2
• Skipping the Dix-Hallpike maneuver—this is the gold standard diagnostic test that can immediately identify the most common cause of dizziness 1, 2
• Assuming normal neurologic exam excludes stroke—75-80% of posterior circulation strokes have no focal deficits 1, 4
• Ordering imaging for straightforward BPPV—this delays treatment unnecessarily 1, 4
• Overlooking vestibular migraine—extremely common but under-recognized in young patients, requires neurology referral 1
• Failing to review medications—antihypertensives, sedatives, anticonvulsants are leading reversible causes of chronic dizziness 1, 4