For a patient presenting with dizziness, how can I determine whether referral to ENT (otolaryngology) or neurology is appropriate?

Determining ENT vs Neurology Referral for Dizziness

Use timing, triggers, and bedside examination findings—not the patient's subjective description—to distinguish peripheral (ENT) from central (neurology) causes, with red flags mandating immediate neurology consultation and imaging. 1, 2

Initial Classification by Timing and Triggers

The American Academy of Otolaryngology-Head and Neck Surgery emphasizes that focusing on specific timing patterns and triggers is far more diagnostically valuable than asking patients to describe their dizziness as "spinning" versus "lightheadedness." 1, 2 This approach categorizes dizziness into four syndromes:

Brief Episodic Vertigo (Seconds to <1 Minute) → ENT

• Triggered by head position changes suggests BPPV, the most common peripheral cause (42% of all vertigo cases) 1, 3
• Perform Dix-Hallpike maneuver bilaterally: look for 5-20 second latency, torsional upbeating nystagmus toward affected ear, crescendo-decrescendo pattern that resolves within 60 seconds 1, 3
• No imaging needed if typical BPPV features present 1, 2

Acute Persistent Vertigo (Days to Weeks) → Depends on Examination

• Suggests vestibular neuritis (41% of peripheral vertigo), labyrinthitis, or posterior circulation stroke (25% of cases, rising to 75% in high vascular risk patients) 1, 3
• Critical decision point: Perform HINTS examination (Head Impulse, Nystagmus, Test of Skew) 1, 3
  • When performed by trained practitioners, HINTS has 100% sensitivity for stroke versus only 46% for early MRI 1
  • Normal head impulse test, direction-changing or vertical nystagmus, or present skew deviation = NEUROLOGY referral immediately 1, 3
  • Abnormal head impulse test, unidirectional horizontal nystagmus, absent skew = likely peripheral, ENT appropriate 1

Spontaneous Episodic Vertigo (Minutes to Hours) → Usually ENT

• Episodes lasting minutes to hours without positional triggers suggest vestibular migraine (14% of vertigo cases), Ménière's disease, or vertebrobasilar TIA 1, 3
• Hearing loss, tinnitus, aural fullness = Ménière's disease → ENT 1, 4
• Headache, photophobia, phonophobia = vestibular migraine → ENT (though often under-recognized) 1
• Episodes <30 minutes with severe postural instability and no hearing loss = vertebrobasilar insufficiency → NEUROLOGY 3, 5

Chronic Vestibular Syndrome (Weeks to Months) → ENT First, Then Consider Neurology

• Review medications (antihypertensives, sedatives, anticonvulsants)—leading reversible cause 1
• Screen for anxiety/panic disorder 1
• If progressive neurologic symptoms or treatment failure → NEUROLOGY 1, 2

Red Flags Requiring IMMEDIATE Neurology Referral

Any of the following mandate urgent MRI brain without contrast and neurology consultation: 1, 3

Nystagmus Patterns

• Pure vertical nystagmus (upbeating or downbeating) without torsional component 1, 3
• Direction-changing nystagmus without head position changes 1, 3
• Baseline nystagmus present without provocative maneuvers 1, 3
• Nystagmus not suppressed by visual fixation and does not fatigue with repeated testing 3, 5
• Gaze-evoked nystagmus (typical of central lesions) 3, 6

Neurologic Signs

• Focal neurological deficits (dysarthria, dysmetria, dysphagia, sensory/motor deficits, diplopia, Horner's syndrome) 1, 3
• Severe postural instability with inability to stand or walk 1, 3
• Truncal or gait ataxia 3
• Limb weakness or hemiparesis 3

Associated Symptoms

• New severe headache accompanying dizziness 1, 3
• Sudden unilateral hearing loss 1, 3
• Failure to respond to appropriate peripheral vestibular treatments (e.g., Epley maneuver for presumed BPPV) 1, 3

High Vascular Risk Features

Even with normal neurologic examination, refer to neurology if patient has: 1, 2

• Age >50 years
• Hypertension
• Diabetes
• Atrial fibrillation
• Prior stroke Rationale: 11-25% of high-risk patients with acute vestibular syndrome have posterior circulation stroke despite normal exam, and 75-80% of stroke patients with acute vestibular syndrome have NO focal neurologic deficits 1, 3

Examination Techniques to Guide Referral

Dix-Hallpike Maneuver Interpretation

Peripheral (BPPV) → ENT: 1, 3

• 5-20 second latency before nystagmus onset
• Torsional and upbeating nystagmus toward affected ear
• Crescendo-decrescendo pattern
• Fatigues with repeat testing
• Resolves within 60 seconds

Central → NEUROLOGY: 1, 3

• Immediate onset without latency
• Purely vertical nystagmus without torsional component
• Persistent, does not fatigue
• Downbeating nystagmus on Dix-Hallpike

HINTS Examination (For Acute Vestibular Syndrome)

Peripheral → ENT: 1

• Abnormal head impulse test (corrective saccade present)
• Unidirectional horizontal nystagmus
• No skew deviation

Central → NEUROLOGY: 1, 3

• Normal head impulse test
• Direction-changing or vertical nystagmus
• Skew deviation present

Common Pitfalls to Avoid

Assuming normal neurologic exam excludes stroke is dangerous: 75-80% of patients with posterior circulation infarct causing acute vestibular syndrome have no focal neurologic deficits 1, 3

Relying on patient's description of "spinning" versus "lightheadedness" is unreliable: Focus instead on timing, triggers, and examination findings 1, 2

Missing vestibular migraine: Extremely common (14% of all vertigo) but under-recognized, particularly in young patients 1, 6

Ordering CT instead of MRI when stroke suspected: CT has <1% diagnostic yield for isolated dizziness and misses most posterior circulation infarcts; MRI with diffusion-weighted imaging has 4% yield 1, 2

Failing to perform Dix-Hallpike when BPPV suspected: This bedside test is diagnostic and obviates need for imaging or specialist referral if positive with typical features 1, 2

Overlooking medication side effects: Leading reversible cause of chronic dizziness, particularly antihypertensives, sedatives, and vestibular suppressants 1

Missing coexisting conditions: 35% of Ménière's patients also meet criteria for vestibular migraine; multiple peripheral vestibular disorders can coexist 1, 3

Imaging Decisions

Do NOT image: 1, 2

• Brief episodic vertigo with typical BPPV features and positive Dix-Hallpike
• Acute persistent vertigo with normal neurologic exam and HINTS consistent with peripheral vertigo (by trained examiner)
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits

MRI brain without contrast indicated → NEUROLOGY: 1, 2, 3

• Abnormal neurologic examination
• HINTS suggesting central cause
• High vascular risk patients with acute vestibular syndrome (even with normal exam)
• Unilateral or pulsatile tinnitus
• Asymmetric hearing loss
• Progressive neurologic symptoms
• Any red flag features listed above

MRI head and internal auditory canal WITH and WITHOUT contrast → ENT: 1

• Chronic recurrent vertigo with unilateral hearing loss or tinnitus (to exclude vestibular schwannoma)
• Suspected Ménière's disease requiring definitive diagnosis

Practical Algorithm

1. Classify by timing: Seconds (BPPV), minutes-hours (migraine/Ménière's/TIA), days-weeks (neuritis/stroke), chronic (multifactorial) 1, 2

2. Check for red flags: If ANY present → NEUROLOGY immediately 1, 3

3. Perform appropriate bedside test: 1, 2

   • Brief episodic → Dix-Hallpike
   • Acute persistent → HINTS examination
   • Check orthostatic vitals if lightheadedness predominates

4. Interpret findings: 1, 3

   • Typical peripheral features + no red flags → ENT
   • Central features or high vascular risk → NEUROLOGY
   • Atypical or equivocal → NEUROLOGY (err on side of caution)

5. Consider associated symptoms: 1, 4

   • Hearing loss/tinnitus/aural fullness → ENT
   • Neurologic symptoms → NEUROLOGY
   • Medication review if chronic → may not need referral