{"id":3885,"date":"2022-05-03T11:47:20","date_gmt":"2022-05-03T10:47:20","guid":{"rendered":"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/entdizzinessandbalance\/"},"modified":"2025-04-09T10:50:41","modified_gmt":"2025-04-09T09:50:41","slug":"entdizzinessandbalance","status":"publish","type":"page","link":"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/entadult\/ear\/entdizzinessandbalance\/","title":{"rendered":"ENT Dizziness and Balance"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\"><strong>Information:<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Intermittent short lived non-positional balance disturbance is very common in all age groups and is probably multifactorial. It is not indicative of any specific or treatable pathology.&nbsp; It does tend to settle over a year or so. Strong reassurance is often all that is required but encourage patients to keep on moving as this helps with habituation.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>ENT Balance Clinic<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">This is a specialised multidisciplinary clinic to investigate those who do not have BPPV and where history and examination makes an otological condition likely.&nbsp; Staff include&nbsp;<\/p>\n\n\n\n<h4 class=\"wp-block-heading\">KEY MESSAGES:<\/h4>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Multiple studies have shown that in patients referred to Balance Clinics:<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>By FAR the commonest diagnoses are BPPV and Vestibular Migraine<\/strong><\/li>\n\n\n\n<li><strong>Please see here for management details:<\/strong>\n<ul class=\"wp-block-list\">\n<li><strong><a href=\"\/refhelp\/guidelines\/BPPVBenignParoxysmalPositionalVertigo\">BPPV<\/a>&nbsp;&#8211;<a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/BPPVBenignParoxysmalPositionalVertigo\/\" data-type=\"URL\" data-id=\"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/BPPVBenignParoxysmalPositionalVertigo\/\" target=\"_blank\" rel=\"noreferrer noopener\">BPPV (Benign Paroxysmal Positional Vertigo) (nhslothian.scot)<\/a>&nbsp;<\/strong><\/li>\n\n\n\n<li><strong>Vestibular migraine \u2013 diagnosis and&nbsp;&nbsp;<a href=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Migraine-in-primary-care-advice-Dec-2022.pdf\" data-type=\"URL\" data-id=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Migraine-in-primary-care-advice-Dec-2022.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Advice for management of migraine in primary care (nhslothian.scot)<\/a><\/strong><\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><strong>A THIRD to HALF of those referred have BOTH BPPV and vestibular migraine.<\/strong><\/li>\n\n\n\n<li><strong>Vestibular Neuritis and central neurological causes of vertigo are associated with a minority.<\/strong><\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">ENT specialists, a specialist Vestibular Audiologist and access to a balance physiotherapist, hearing tests and other Audiology services.&nbsp;&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">According to the history and examination, it may be advisable to exclude anaemia, diabetes or thyroid disorder.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The history is key, with four main groups of patients:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Peripheral vertigo \u2013 BPPV by far the commonest see <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/audiology\/bppvbenignparoxysmalpositionalvertigo\/\">BPPV (Benign Paroxysmal Positional Vertigo) \u2013 RefHelp<\/a><\/li>\n\n\n\n<li>Vestibular migraine (and less commonly other neurological conditions)<\/li>\n\n\n\n<li>Balance issues in the elderly (multifactorial \u2013<a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/medicineoftheelderlygeriatrics\/dizziness\/\">Dizziness \u2013 RefHelp<\/a>\u00a0)<\/li>\n\n\n\n<li>Cardiovascular causes.<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">The ENT balance team will ask patients to complete a symptom questionnaire online prior to being given an appointment, with the option of a phone&nbsp;call for those who cannot manage this.<\/p>\n\n\n\n<figure class=\"wp-block-image\"><img decoding=\"async\" src=\"\/files\/sites\/2\/ENT-Dizzines-and-Balance.png\" alt=\"ENT Dizziness and Balance\" \/><figcaption class=\"wp-element-caption\">flowchart copyright of NHS Lothian<\/figcaption><\/figure>\n\n\n\n<h4 class=\"wp-block-heading\">Link 1-&nbsp;<a href=\"\/refhelp\/guidelines\/BPPVBenignParoxysmalPositionalVertigo\" target=\"_blank\" rel=\"noreferrer noopener\">BPPVBenignParoxysmalPositionalVertigo.aspx<\/a><\/h4>\n\n\n\n<h4 class=\"wp-block-heading\">Link 2-&nbsp;<a href=\"\/refhelp\/guidelines\/Dizziness\" target=\"_blank\" rel=\"noreferrer noopener\">Dizziness.aspx<\/a><\/h4>\n\n\n\n<h4 class=\"wp-block-heading\">Link 3-&nbsp;<a href=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Migraine-in-primary-care-advice-Nov-2024.pdf\" data-type=\"URL\" data-id=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Migraine-in-primary-care-advice-Dec-2022.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Advice for management of migraine in primary care (nhslothian.scot)<\/a><\/h4>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Please see the Primary Care Management page for more detail.<\/strong><\/p>\n\n\n\n<div class=\"wp-block-getwid-tabs\" data-active-tab=\"0\"><ul class=\"wp-block-getwid-tabs__nav-links\"><\/ul>\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Referral Guidelines<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<h4 class=\"wp-block-heading\">Who to refer:<\/h4>\n\n\n\n<ul class=\"wp-block-list\">\n<li>&nbsp;&gt; 6weeks dizziness and balance problems for diagnosis and management:<\/li>\n\n\n\n<li>Probable Meniere&#8217;s \u2013 see&nbsp;<a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/menieresdisease\/\" data-type=\"URL\" data-id=\"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/menieresdisease\/\" target=\"_blank\" rel=\"noreferrer noopener\">Menieres disease<\/a>.<\/li>\n<\/ul>\n\n\n\n<h4 class=\"wp-block-heading\">Who not to refer:<\/h4>\n\n\n\n<p class=\"wp-block-paragraph\">Those with vestibular migraine:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Standard Primary Care\u00a0 treatments are outlined\u00a0<a href=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Migraine-in-primary-care-advice-Nov-2024.pdf\" data-type=\"URL\" data-id=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Jan-18-NHS-Lothian-advice-for-management-of-migraine-in-primary-care.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">management of migraine<\/a><\/li>\n\n\n\n<li>Please refer to Neurology for those not responding to first line treatments<\/li>\n\n\n\n<li>People over 65, particularly with co-morbidities, where the indications are that this is multifactorial \u2013 please see&nbsp;<a rel=\"noreferrer noopener\" href=\"\/refhelp\/MedicineofElderlyGeriatrics\/dizziness\" data-type=\"URL\" data-id=\"\/refhelp\/MedicineofElderlyGeriatrics\/dizziness\" target=\"_blank\">Dizziness<\/a><\/li>\n\n\n\n<li>Those with syncopal or pre-syncopal symptoms &#8211; please refer to Cardiology if suspicion of cardiac disease or arrythmias.<\/li>\n<\/ul>\n\n\n\n<h4 class=\"wp-block-heading\">How to refer:<\/h4>\n\n\n\n<p class=\"wp-block-paragraph\"><br>To ENT via SCI Gateway (specific SCI Gateway referral pathway under development).<\/p>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Primary Care Management<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<p class=\"wp-block-paragraph\">The history establishes if vertigo is:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>truly rotational (rather than light-headedness or unsteadiness)<\/li>\n\n\n\n<li>CENTRAL or PERIPHERAL \u2013 distinguishing may be helped by the HiNTS test (please see\u00a0<a href=\"\/refhelp\/MedicineofElderlyGeriatrics\/dizziness#tabs-2\" target=\"_blank\" rel=\"noreferrer noopener\">Medicine of the Elderly<\/a>\u00a0for Primary Care approaches and\u00a0<a href=\"https:\/\/www.youtube.com\/watch?v=1q-VTKPweuk\" target=\"_blank\" rel=\"noreferrer noopener\">here<\/a>\u00a0for a demonstration).<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\"><br><strong><em>If CENTRAL, consider the possibility of an acute cerebral event.<\/em><\/strong><br><br>Prochlorperazine may be useful short-term, but prolonged use is not recommended.<\/p>\n\n\n\n<h4 class=\"wp-block-heading\">Symptoms can be considered in four main symptom clusters:<\/h4>\n\n\n\n<ol class=\"wp-block-list\">\n<li><strong>VERTIGO \u2013 peripheral causes<\/strong>:<\/li>\n<\/ol>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Intermittent brief episodes, precipitated by head movement&nbsp; or other postural changes are likely to be BPPV \u2013 see <a href=\"\/refhelp\/Audiology\/bppv-(benign-paroxysmal-positional-vertigo)\">Audiology<\/a>&nbsp;for details<\/li>\n\n\n\n<li>Acute onset with persistent symptoms:\n<ul class=\"wp-block-list\">\n<li>Vestibular neuritis (no hearing loss) or<\/li>\n\n\n\n<li>Labyrinthitis (often following infection and associated with unilateral hearing loss).<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Meniere&#8217;s disease\u00a0is rare and associated with prolonged incapacitating episodes of vertigo, as well as hearing loss and tinnitus \u2013 please see\u00a0<a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/entadult\/ear\/menieresdisease\/\">Menieres Disease \u2013 RefHelp<\/a>\u00a0for more detail. There is commonly an element of BPPV when there is a mixture of symptoms \u2013 always worth treating that first.<\/li>\n<\/ul>\n\n\n\n<ol start=\"2\" class=\"wp-block-list\">\n<li><strong>MIGRAINE and other neurological causes<\/strong><\/li>\n<\/ol>\n\n\n\n<p class=\"wp-block-paragraph\">MIGRAINE can cause true rotatory vertigo&nbsp;associated with light sensitivity +\/- headache, occurring with menstrual cycle or more frequently, a past history of migraine.<br>Vestibular Migraine (previously known as migraine-associated vertigo)&nbsp; &#8211; please see guidance&nbsp;here&nbsp;for initial management, before any referral&nbsp; to the multidisciplinary balance clinic.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Vertigo may be associated with other central neurological conditions, including multiple sclerosis, cardiovascular events and Parkinson&#8217;s Disease.<\/p>\n\n\n\n<ol start=\"3\" class=\"wp-block-list\">\n<li><strong>OLDER PEOPLE especially in the presence of co-morbidities.<\/strong><strong>&nbsp;<\/strong><\/li>\n<\/ol>\n\n\n\n<p class=\"wp-block-paragraph\">Balance disturbance is often central or multifactorial \u2013 please see the Medicine of the Elderly pathway\u00a0<a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/medicineoftheelderlygeriatrics\/dizziness\/\">Dizziness \u2013 RefHelp<\/a>\u00a0for further detail. The team will see patients with vertigo where that is part of a more complex picture. Some may benefit from referral to the\u00a0<a href=\"\/refhelp\/MedicineofElderlyGeriatrics\/falls\" target=\"_blank\" rel=\"noreferrer noopener\">falls pathway<\/a>.\u00a0<\/p>\n\n\n\n<ol start=\"4\" class=\"wp-block-list\">\n<li><strong>CARDIOVASCULAR CAUSES<\/strong><\/li>\n<\/ol>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Tend to cause dizziness without vertigo \u2013 syncopal or pre-syncopal symptoms<\/li>\n\n\n\n<li>Often precipitated by standing up<\/li>\n\n\n\n<li>Causes include postural hypotension, cardiac arrythmias or severe aortic stenosis<\/li>\n\n\n\n<li>Please see <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/medicineoftheelderlygeriatrics\/dizziness\/\">Dizziness \u2013 RefHelp<\/a>\u00a0\u00a0for further detail.<\/li>\n<\/ul>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Resources and Links<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<p class=\"wp-block-paragraph\"><\/p>\n<\/div><\/div>\n<\/div>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Information: Intermittent short lived non-positional balance disturbance is very common in all age groups and is probably multifactorial. It is not indicative of any specific or treatable pathology.&nbsp; It does tend to settle over a year or so. Strong reassurance is often all that is required but encourage patients to keep on moving as this<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":3886,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_searchwp_excluded":"","footnotes":""},"categories":[139],"class_list":["post-3885","page","type-page","status-publish","hentry","category-dizziness-and-balance"],"publishpress_future_workflow_manual_trigger":{"enabledWorkflows":[]},"rttpg_featured_image_url":null,"rttpg_author":{"display_name":"NHS Lothian","author_link":"https:\/\/apps.nhslothian.scot\/refhelp\/author\/nhs-lothian\/"},"rttpg_comment":0,"rttpg_category":" <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/category\/entadult\/ear\/dizziness-and-balance\/\" rel=\"tag\">Dizziness and Balance<\/a>","rttpg_excerpt":"Information: Intermittent short lived non-positional balance disturbance is very common in all age groups and is probably multifactorial. It is not indicative of any specific or treatable pathology.&nbsp; It does tend to settle over a year or so. Strong reassurance is often all that is required but encourage patients to keep on moving as this","_links":{"self":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/3885","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/comments?post=3885"}],"version-history":[{"count":17,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/3885\/revisions"}],"predecessor-version":[{"id":28353,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/3885\/revisions\/28353"}],"up":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/3886"}],"wp:attachment":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/media?parent=3885"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/categories?post=3885"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}