Which specialist should be consulted for a patient presenting with dizziness?

Specialist Referral for Dizziness

Patients with dizziness should initially be evaluated by either an otolaryngologist (ENT) or a neurologist, with the choice depending on the clinical presentation and timing pattern of symptoms. 1, 2

Primary Specialist Selection Algorithm

Otolaryngologist (ENT) as First-Line Specialist

• Brief episodic vertigo (seconds to <1 minute) triggered by positional changes strongly suggests BPPV, which is best managed by ENT specialists who routinely perform Dix-Hallpike maneuvers and canalith repositioning procedures 1, 2
• Spontaneous episodic vertigo (minutes to hours) with associated hearing loss, tinnitus, or aural fullness suggests Ménière's disease, requiring ENT evaluation for audiometric testing and intratympanic treatments 1, 3
• Chronic recurrent vertigo with unilateral hearing symptoms warrants ENT consultation to exclude vestibular schwannoma and manage peripheral vestibular disorders 3

Neurologist as First-Line Specialist

• Acute vestibular syndrome (days to weeks) with high vascular risk factors (age >50, hypertension, diabetes, atrial fibrillation, prior stroke) requires neurologist evaluation to exclude posterior circulation stroke, which accounts for 25% of acute vestibular syndrome cases 1, 2
• Red flag features including focal neurological deficits, downbeating or direction-changing nystagmus, inability to stand or walk, new severe headache, or abnormal HINTS examination mandate immediate neurologist consultation 1, 2
• Vestibular migraine (14% of all vertigo cases) presenting with episodes lasting 5 minutes to 72 hours accompanied by migraine symptoms requires neurologist management for prophylaxis 1, 3
• Central vestibular syndromes with cerebellar signs, gaze-evoked nystagmus, or progressive neurologic symptoms require neurologist evaluation 2, 3

Critical Decision Points

When Both Specialties May Be Appropriate

• Chronic dizziness without clear peripheral or central features can be evaluated by either specialty, though neurologists and ENT physicians report similar diagnostic confidence (60% reaching specific diagnosis at first consultation for episodic/chronic dizziness) 4
• Vestibular neuritis (41% of peripheral vertigo cases) may be managed by either ENT or neurology, though neurologists have specific expertise in cortisone treatment protocols 5

Common Referral Pitfalls to Avoid

• Primary care physicians refer only 22% of dizzy patients to specialists, geriatricians 17%, and emergency physicians 16%, contributing to underdiagnosis 6
• 89% of providers fail to perform positional nystagmus testing for BPPV evaluation, missing the most common cause of vertigo (42% of all cases) 6
• Over two-thirds of providers (69%) rely on patient's subjective description rather than timing and triggers, leading to diagnostic errors 6
• Normal neurologic examination does NOT exclude stroke, as 75-80% of posterior circulation stroke patients have no focal deficits 1, 2

Practical Referral Strategy

Immediate Neurologist Referral Required

• Focal neurological deficits on examination 1, 2
• Sudden unilateral hearing loss 1, 3
• Inability to stand or walk 1, 2
• Downbeating or central nystagmus patterns 1, 2
• New severe headache with dizziness 1, 3
• HINTS examination suggesting central cause (normal head impulse test, direction-changing nystagmus, skew deviation present) 1, 2

ENT Referral Appropriate

• Positive Dix-Hallpike test with typical BPPV features 1, 2
• Fluctuating hearing loss with episodic vertigo 1, 3
• Unilateral tinnitus or pulsatile tinnitus 1, 3
• Asymmetric hearing loss requiring vestibular schwannoma exclusion 3

Dual Consultation May Be Needed

• 35% of Ménière's patients also meet criteria for vestibular migraine, requiring both ENT and neurology input 3
• Atypical presentations where peripheral versus central differentiation remains unclear after initial specialist evaluation 4, 7

The key determinant is whether the clinical presentation suggests peripheral vestibular pathology (ENT) versus central nervous system involvement (neurology), with timing, triggers, and associated symptoms guiding this distinction rather than the patient's subjective description of dizziness. 1, 2, 6