Evaluation of the dizzy patient: experience from a multidisciplinary neurotology clinic

A review of primary care referrals for patients with dizziness and vertigo: prevalence and demographics

BACKGROUND

International studies show that dizziness and vertigo are a significant burden on the general population, with 20-30% experiencing symptoms over a lifetime. There are no Irish studies indicating prevalence. The aim of this study was to review primary care referrals for patients with dizziness and vertigo to an otolaryngology tertiary centre.

METHODS

A review of an out-patient department waiting list was performed on primary care referrals for dizziness and vertigo to an otolaryngology tertiary centre. Demographic information was recorded on all patients referred between May 2017 and August 2019.

RESULTS

Two hundred fifteen patients out of 901 patients (24%) referred to an otologist between May 2017 and August 2019 were referred with dizziness as a presenting complaint. The average age was 51 years. F/M ratio was 3:2. The average waiting time was 441 days. The most common associated otological symptom was tinnitus (42%). Relevant comorbidities included anxiety, depression, migraine/headaches and cardiac disease.

CONCLUSION

This study demonstrates that a significant number of patients referred to an otologist from primary care are referred with dizziness and vertigo and supports the need for the establishment of multi-disciplinary vestibular/balance centres to address and manage these patients.

A retrospective analysis of two tertiary care dizziness clinics: a multidisciplinary chronic dizziness clinic and an acute dizziness clinic

Background

Vertigo remains a diagnostic challenge for primary care, emergency, and specialist physicians. Multidisciplinary clinics are increasingly being employed to diagnose and manage patients with dizziness. We describe, for the first time in Canada, the clinical characteristics of patients presenting with chronic and acute dizziness to both a multidisciplinary chronic dizziness clinic (MDC) and a rapid access dizziness (RAD) clinic at The Ottawa Hospital (TOH).

Methods

We performed a retrospective review of all patients presenting to the MDC and RAD clinics at TOH from July 2015 to August 2017.

Results

Overall, 211 patients (median age: 61 years old) presented to the RAD clinic and 292 patients (median age: 55 years old) presented to the MDC. In the RAD clinic, 63% of patients had peripheral dizziness, of which 55% had BPPV, and only one patient had functional dizziness. Interestingly, only 25% of RAD diagnoses were concordant with emergency department diagnoses; moreover, only 33% of RAD patients had HiNTS completed, while 44% had CT scans, of which only one scan had an abnormal finding. Prior to assessment, all patients in the MDC had an unclear cause of dizziness. 28% of patients had vestibular dizziness and 21% had functional dizziness, of which 43% had persistent postural perceptual dizziness. Moreover, 12% of patients with functional dizziness also suffered from comorbid severe anxiety and depression.

Conclusions

Dizziness is a heterogeneous disorder that necessitates multidisciplinary care, and clinics targeting both the acute and chronic setting can improve diagnostic accuracy, ensure appropriate diagnostic testing, and facilitate effective care plans for patients with dizziness.

Referrals to a specialised dizziness clinic often result in revised diagnoses and new therapeutic advice

BACKGROUND

Patients with dizziness are frequently referred to specialised centres for a second opinion. The incremental diagnostic and therapeutic yield of this approach has rarely been studied.

AIM OF THE STUDY

How often is a new diagnosis or treatment advice given to patients with dizziness who are referred for a second opinion to a tertiary multi-disciplinary expertise centre?

METHODS

In a prospective observational study, the following data were collected: reason for referral, diagnosis and treatment made by ENT surgeon and a neurologist in consensus.

RESULTS

In the complete group of patients (n = 327), a new (or amended) diagnosis was made in 54% and 62% of the patients received a new treatment advice.

CONCLUSION

Referral of selected dizzy patients to a multidisciplinary centre provides a revised diagnosis or treatment recommendation for a majority of patients.

Unexplained dizziness does not resolve in time

Only few patients with dizziness are referred to a medical specialist, who is sometimes unable to come to a conclusive cause of the dizziness. We have no information about the course of unexplained dizziness, from the literature or from our own population. We therefore undertook this follow-up study to assess the outcome of patients with unexplained dizziness, after assessment in a multidisciplinary outpatient clinic. In 292 patients (out of our total cohort of 2,244 patients), a diagnosis could not be established. The median dizziness handicap inventory (DHI) score at the diagnostic visit was 30. We sent them a questionnaire and the DHI. After a median follow-up of 62 months (range 24-105 months), 113 of the 189 responders (60%) reported to still suffer from dizziness, 46 patients had moderate impairments, and 16 patients indicated that they were severely impaired by their dizziness. The DHI only slightly decreased (from median 30 to 26). In 1% of the cases, an organic explanation for the dizziness was ultimately found during follow-up by other health-care workers. Patients who have been assessed in a multidisciplinary dizziness clinic, and in whom no explanatory cause for the dizziness has been found, have a high risk of persisting impairments.

Causes and time-course of vertigo in an ear, nose, and throat clinic

The purpose of this study is to review etiologies and identify the time-course of vertigo presenting in an ear, nose, and throat clinic, and serve as a reference guide for other clinics. The study includes retrospective chart review in a tertiary care, university hospital. The patient data with reported ICD-10 codes as causes of vertigo between April 2005 and December 2007 were extracted from the database. At each visit, the main diagnosis as to etiology, characteristics of the vertigo, its time-course, and patient demographic data were recorded. Of 547 cases, 17 diagnoses were made in 73.9%. Diagnostic categories included peripheral vertigo 72.9%, central vertigo 0.8%, psychogenic cause 0.2%, and unknown 26.1%. Common causes of vertigo were benign paroxysmal positional vertigo (BPPV) 52.5%, Meniere's disease 14.6%, and sudden idiopathic hearing loss 2.9%. Less common diagnoses were benign paroxysmal vertigo of childhood 0.7%, labyrinthitis 0.7%, and vestibular schwannoma 0.3%. Rare conditions were delayed endolymphatic hydrops, Ramsey Hunt syndrome, otosyphilis, vestibular neuritis, temporal bone fracture, post-concussion syndrome, cerebellar infarction, epilepsy, cervical vertigo, Streptococcus suis meningitis, and psychogenic vertigo. Ninety-nine cases who reported remission of vertigo during the study period had median onset of the remission at 4 weeks. In the ear, nose, and throat clinic at Chiang Mai University, a tertiary university hospital, peripheral vestibular disorders were the main etiology of vertigo. The three most common causes were BPPV, Meniere's disease, and sudden idiopathic hearing loss. Half of the cases who returned for follow up had remitted symptoms within 4 weeks.

What proportion of patients referred to an otolaryngology vertigo clinic have an otological cause for their symptoms?

Background:

Dizziness is a common and often complex complaint. Between nine and 13 per cent of patients seen in general practice are referred to a variety of specialist clinics. The diagnoses and outcomes of these referrals are seldom reported.

Aims:

To determine the proportion of patients referred to an otology led vertigo clinic in whom an otological cause for vertigo could be identified.

Design of study:

Prospective cohort study of consecutive new clinic attendees over one year.

Setting and methods:

Otology led vertigo clinic in an urban teaching hospital in England. Patients' details including age, sex, referring clinician, investigations, diagnoses, treatment and final outcome were recorded in an anonymised database.

Results:

91 new patients, 31 men and 60 women with a mean age of 52.6 years (range 16–81) were seen. General practitioners referred 87 per cent of the patients. Twenty-seven patients underwent further investigations including imaging, electronystagmography and other audiological tests. A labyrinthine disorder accounted for 50 per cent of the diagnoses. Ménière's disease or a variant was diagnosed in 20 patients (21 per cent). Fifty-six patients (61 per cent) reported resolution of or improvement in their symptoms. Thirty-one patients (34 per cent) were asymptomatic and free of abnormal findings on initial attendance and were discharged from hospital care.

Conclusions:

Forty-six patients (50.6 per cent, 95 per cent confidence interval, 40.4–60.6 per cent) had vertigo due to an otological disorder. The selection of an otolaryngology based vertigo clinic by the general practitioner for initial referral seems appropriate.

Primary assessment of the vertiginous patient at a pre-ENT balance clinic

Introduction:

Due to problems with long waiting times for assessment of vertiginous patients (more than 24 weeks), we changed practice and instituted a pre-ENT balance clinic assessment; we then audited the results. In particular, we looked at the subgroup with benign positional paroxysmal vertigo.

Methods:

One hundred and fifteen patients were seen at the pre-ENT balance clinic from October 2003 to September 2004. Those diagnosed with benign positional paroxysmal vertigo received particle repositioning therapy at the same clinic and did not subsequently need ENT assessment.

Results:

By the end of the audit period, waiting times were reduced to three weeks, and more than one-quarter of vertiginous patients (i.e. those diagnosed with benign positional paroxysmal vertigo) did not need to be reviewed at an ENT clinic.

Conclusion:

We believe this to be the first study to present prospective data showing that patients with benign positional paroxysmal vertigo may be safely diagnosed and effectively managed at a pre-ENT balance clinic.

Long-term results of posterior semicircular canal occlusion for intractable benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is a common condition which is usually managed conservatively, surgical intervention being recommended only for those small number of patients in whom it becomes persistent and incapacitating. The results of surgery in 13 patients who underwent posterior semicircular canal occlusion for intractable (> 12 months duration) and incapacitating BPPV are presented with special emphasis on their long-term follow-up. The mean follow-up was 66 months (range, 29-119 months). All patients reported complete and immediate resolution of their positional vertigo, which has been maintained in the long term. Most patients, however, reported some postoperative transient unsteadiness which lasted up to 4 weeks. All patients developed a transient mild conductive hearing loss secondary to a middle ear collection, which usually resolved within 4 weeks. Five patients developed a transient mild high frequency sensorineural hearing loss which resolved in all cases within 6 months. There were no reports of sensorineural hearing loss nor tinnitus in the long term. All patients believed that the operation was beneficial and would undergo it again. Our findings indicate that posterior semicircular canal occlusion is an effective and safe operation in the long term and is the procedure of choice for intractable and incapacitating BPPV rather than singular neurectomy.