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Dizziness Care Pathway Overview

This pathway has been developed to provide clear guidance to GPs on the management of dizziness in order to support GP assessment and management, and provide guidance on appropriate referral routes.

Dizziness is a non-specific term often used by patients to describe symptoms. The most common complaints included under the heading dizziness comprise:

  • Vertigo
  • non-specific light-headedness
  • disorientation
  • imbalance
  • presyncope

Dizziness is a common symptom that is responsible for considerable handicap and psychological morbidity and may result from disturbance in a number of systems:

  • visual
  • proprioceptive
  • peripheral vestibular system (about 40% of cases)
  • cardiovascular
  • central nervous system (about 10% of cases)
  • psychological or psychiatric (about 15% of cases)
  • auto-immune disorders (systemic, inner ear)

Dizziness may be caused by a variety of general medical conditions.

Dizziness conditions such as benign paroxysmal positional vertigo, vestibular neuronitis and familial vestibulopathy selectively affect the peripheral vestibular system without any hearing loss.

There are four broad categories of balance dysfunction:

  • vertigo
    • defined as an illusion or hallucination of movement often with a rotatory element and is typically thought to arise from an abnormality involving the peripheral or central vestibular pathways:
      • objective vertigo is the illusion that one's surroundings are moving
      • subjective vertigo is the feeling that with eyes closed one's body or head is moving or turning in space
  • disequilibrium
    • defined as a feeling of imbalance or unsteadiness
  • near-syncope
    • defined as light-headedness, dizziness and giddiness, representing a sensation of being about to faint:
      • it is important to realise that not all dizziness is vertigo, even though patients may describe vertigo as dizziness
  • Non-specific light-headedness
    • occurs without true vertigo, near-syncope or disequilibrium

                               

Red Flags
  • irregular pulse (consider cardiac arrhythmia)
  • abnormal neurological examination (consider cerebrovascular accident, central nervous system [CNS] medications, multiple sclerosis)
  • history of cervical spine or head trauma
  • recent history of aminoglycosideantibiotics, diuretics or chemotherapy (consider bilateral vestibular dysfunction)
  • history of barotrauma (consider round window rupture or perilymph fistula)
  • associated with hearing loss and/or tinnitus (consider Meniere's disease, acoustic neuroma, bilateral vestibular dysfunction)
  • chronic dizziness (uncompensated vestibular dysfunction) lasting more than 4 weeks
Differential Diagnosis

Neurological disorders of gait may present as ataxia. Check for a positive rhombergs sign.

Ataxia is an unsteady and clumsy motion of the limbs or trunk due to a failure of the gross coordination of muscle movements.

Several types of ataxia are possible, including:

  • cerebellar ataxia
  • sensory ataxia
  • vestibular ataxia

Specific ataxias include:

  • Friedreich's ataxia
  • spinocerebellar ataxia
  • episodic ataxia
  • ataxia-telangiectasia

People with suspected ataxia should be referred to a neurologist for further evaluation.

Dizziness associated with a hallucination of motion:

  • Patients may refer to the sensation of dizziness from pre-syncope, hyperventilation or anxiety as 'giddiness', 'dizziness' or 'light-headedness'.

Consider Vertigo

Initial Primary Care Assessment

  • the exact sensation
  • the time course of the dizziness; is it episodic (eg benign paroxysmal positional vertigo [BPPV], migraine, Meniere's postural hypotension), or is it present much of the time (e.g. vestibulopathy or psychological)
  • when the dizziness occurs

  • nausea
  • vomiting
  • headache
  • hearing loss or tinnitus
  • loss of consciousness
  • recent head injury

Ask the patient about any symptoms that may indicate a central nervous system (CNS) cause for their dizziness, e.g. dysarthria

A general medical history will be required, which should include a review of medications that may cause dizziness or postural hypotension.

  • pulse
  • blood pressure (lying and standing)
  • test vestibular function:
    • look for presence of nystagmus
    • Hallpike manoeuvre
  • cardiovascular:
    • murmurs
    • abnormal rhythm
  • neurological:
    • look for any signs that may indicate a central disorder, such as motor weakness, dysmetria, sensory changes, etc.
  • also consider:
    • cerebellar
    • focal deficit

  • nystagmus:
    • is more likely to be vertical, and to be 'slow to fatigue' in central than in peripheral vertigo
    • Hallpike's test is critical - upbeat geotropic torsional nystagmus should be seen, if other types of nystagmus are seen, consider central causes
  • nausea and vomiting:
    • tends to be more severe in peripheral than in central vertigo
  • associated neurological symptoms:
    • rare in peripheral vestibular disorders as opposed to central vestibular dysfunction
  • compensation:
    • peripheral vestibular failure can leave a patient feeling dizzy and unsteady for weeks
    • slow or incomplete in central vestibular disturbance

 

Dizziness only on ambulation:

  • is most likely to result from a peripheral vestibular disturbance in the absence of neurological symptoms or signs
  • in the elderly multi-system dizziness is common

Consider referral to Physiotherapy for vestibular rehabilitation (see below)

If symptoms persist consider referral to ENT

 

Dizziness associated with light-headedness

Patients may refer to the sensation of dizziness from pre-syncope, hyperventilation or anxiety as 'giddiness', 'dizziness' or 'light-headedness'.

Consider syncope – consider referral to Dr Deering, syncope clinic

Consider psychiatric cause; anxiety / depression (see pathways for further info)

Consider referral to Physiotherapy for hyperventilation

 

Multi-system dizzy syndrome

Dizziness is the commonest reason patients over the age of 75 see their GP. In the elderly there are usually multiple causes and the following should be considered:

  • peripheral vestibular deficits including benign paroxysmal positional vertigo (BPPV)
  • central vestibular deficits
  • cardiovascular disease
  • diabetes
  • peripheral neuropathy
  • orthopaedic disorder
  • poor eyesight
  • medication

Referral to a falls prevention programme may be appropriate.

When to Refer

Consider referral to Physiotherapy for Vestibular Rehabilitation or Hyperventilation (see below)

Consider referral to falls prevention programme for multi-system dizzy syndrome

Consider referral to ENT if:

  • symptoms persist following conservative management

Or

  • further investigations are needed to confirm diagnosis
Secondary Care Management - Physiotherapy

Vestibular rehabilitation is the assessment and management of patients suffering from feelings of dizziness/unsteadiness due to incorrect function of balance organs in the inner ear (vestibular disorder). Often when symptoms of dizziness or unsteadiness have been present for some time poor compensation of the balance system occurs and a graded exercise based treatment is required to improve symptoms.

Vestibular Rehabilitation will help the brain to process information it receives from the body in a new way to help return balance and reduce symptoms.

Vestibular Rehabilitation can help many people with their symptoms but assessment of these symptoms is required to guide patients to perform an individualised exercise programme suited to them. It may be useful for those who have episodic recurrent symptoms or those who are presenting with their first episode of vertigo. A physiotherapist will assess the patients' particular needs and tailor treatment accordingly.

It can involve:

  • Exercise based treatments
  • Psychological support
  • Guidance with relaxation therapies led by Physiotherapist and Hearing Therapists.

 

Direct referrals can be made to your local Physiotherapy department to see a physiotherapist who works within Vestibular Rehabilitation. Hearing Therapy is a pathway for complex patients e.g. Meniere's, the Physiotherapists and ENT department refer direct to Hearing Therapy. This service is not directly available to GPs.

Patients can choose to access Vestibular Rehabilitation provided by Gloucestershire Hospitals NHS Foundation Trust  at any of the sites listed below, either via GP letter referral  - please email your referral document to ghn-tr.physiotherapy@nhs.net

or 

self-referral using this online self-referral form:

  • Gloucestershire Royal Hospital
  • Cheltenham General Hospital
Secondary Care Management - ENT

In secondary or tertiary care, the following tests may be considered:

  • audio-vestibular:
    • pure tone audiogram
    • auditory brain stem responses
    • electronystagmography
    • posturography
    • caloric test
  • radiological:
    • magnetic resonance image (MRI)
    • computed tomography (CT) scan of temporal bones
    • cervical spine X-ray
    • MRI angiography
    • transcranial Doppler ultrasound

 

For Meniere’s disease, see vertigo pathway; ablative surgery or medical procedure may be considered:

  • intra-tympanic gentamicin has been shown to abolish the vertigo of Meniere's disease in 80% of those treated and greatly reduces it in 96%; it has become an important treatment for this condition
  • intra-tympanic dexamethasone is advocated by some, but evidence remains incomplete on its effectiveness
  • endolymphatic sac surgery
  • vestibular nerve section/neurectomy
  • labyrinthectomy
Ongoing Care

Following diagnosis a treatment strategy will be devised to control symptoms.

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