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Vertigo / Vestibular (Audiology)

ADULT

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.


Adult

  • Hearing loss
    • Sudden loss or sudden deterioration of hearing (sudden = within 72 hours) (British Academy of Audiology, 2016)
  • Otitis media
    • Any suspicions of the complications of ASOM i.e. Mastoiditis (proptosis of pinna), meningitis etc
  • Vertigo/Vestibular
    • Recent sudden onset with neurological symptoms
  • Facial Nerve Palsy
    • Sudden onset facial weakness

Paediatric

  • Paediatric Hearing loss
    • Sudden loss or deterioration
  • Paediatric Otitis media
    • Any suspicions Mastoiditis (proptosis of pinna), meningitis or other complication of ASOM
    • Trauma
    • New onset facial nerve palsy
  • Other referrals to emergency not covered within these conditions (Paediatric)
    • Foreign body
    • ENT conditions with associated neurological signs e.g. facial nerve palsy, profound vertigo and/or sudden deterioration in sensorineural hearing
    • Acute and/or complicated mastoiditis
    • Auricular haematoma
    • Significant head injury
    • Congenital abnormality of the head/neck
    • Meningitis/encephalitis
  • Refer to ENT CPC, Health pathways or local guidelines particularly if has associated otological symptoms/conditions
  • Refer to Neurologist if has associated neurological symptoms (non-acute) or suspected vestibular migraine (send to Emergency if acute with neurological symptoms).
  • Perform Dix-Hallpike Manoeuvre, Head Impulse Test (HIT) and/or HINTS tests to determine likely cause of vertigo.
  • If BPPV is likely based on symptoms and a positive Dix-Hallpike (patient reports subjective vertigo & torsional nystagmus observed), then treat with canalith repositioning manoeuvre (e.g. Epley manoeuvre) and consider referral to a vestibular physiotherapist
  • If HIT unilaterally positive with acute vertigo, consider vestibular neuritis
  • Consider referral to Vestibular Physiotherapist for vertigo with no associated neurological / central signs.
  • Occupational therapy home assessment for falls prevention
  • Consider advice regarding safe driving/licencing
  • Consider MedsCheck with Pharmacist if polypharmacy possible (≥ 5 daily medications)
  • Check ear canals (otoscopy) before referring to Audiology for vestibular function testing – canals must be completely clear of all wax / debris to enable complete / reliable vestibular function testing (refer to ENT for wax removal if unable to be managed in GP clinic).

Clinical resources

Patient resources

Minimum Referral Criteria

  • Category 1
    (appointment within 30 calendar days)
    • No category 1 criteria

    NB: recent, sudden onset dizziness / vertigo with associated neurological symptoms should be referred to Emergency ASAP.

  • Category 2
    (appointment within 90 calendar days)
    • Recent sudden onset with no neurological symptoms
    • Symptoms are preventing ability to work / maintain employment
  • Category 3
    (appointment within 365 calendar days)
    • Suspected benign paroxysmal positional vertigo (BPPV) not responding to repeated canalith repositioning manoeuvres (> 3 treatments)
    • Co-morbid vestibular or otological conditions
    • Symptoms not resolved after seeing vestibular physiotherapist
    • Chronic dizziness

1. Reason for request Indicate on the referral

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

2. Essential referral information Referral will be returned without this

  • Description of:
    • Dizziness/balance symptoms (vertigo, disequilibrium, light-headed etc)
    • onset, duration, frequency and positional
    • functional impact of dizziness
    • any associated otological/neurological symptoms (e.g. changes to hearing/tinnitus, onset of headache)
    • any previous diagnosis of dizziness (attach correspondence)
    • any treatments (medication/other) previously tried, duration of trial and effect
    • any previous investigations/imaging results
    • past history of middle ear disease/surgery

3. Additional referral information Useful for processing the referral

  • History of any of the following:
    • cardiovascular problems [e.g. stroke, TIA, vertebro-basilar artery insufficiency]
    • neck problems [cervical degeneration, Chiari malformation etc.]
    • neurological conditions [epilepsy/seizures, MS, Parkinson’s etc.]
    • auto immune conditions/diabetes
    • eye problems [blindness, history of retinal detachments, eye muscle weakness/lazy eye etc.]
    • migraine history
    • previous head injury
  • Current medication list
  • Investigations and/or other conditions eliminated as a causative factor for vestibular problems.
  • Results of any diagnostic investigations to date to determine cause of vestibular symptoms
  • Previous treatment with vestibulo-toxic / ototoxic medications (Gentamycin, Cisplatin etc.)
  • History of drug and alcohol abuse
  • Psychological history [anxiety and/or claustrophobia etc.]

4. Request

Patient's Demographic Details

  • Full name (including aliases)
  • Date of birth
  • Residential and postal address
  • Telephone contact number/s – home, mobile and alternative
  • Medicare number (where eligible)
  • Name of the parent or caregiver (if appropriate)
  • Preferred language and interpreter requirements
  • Identifies as Aboriginal and/or Torres Strait Islander

Referring Practitioner Details

  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature

Relevant clinical information about the condition

  • Presenting symptoms (evolution and duration)
  • Physical findings
  • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
  • Body mass index (BMI)
  • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
  • Current medications and dosages
  • Drug allergies
  • Alcohol, tobacco and other drugs use

Reason for request

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

Clinical modifiers

  • Impact on employment
  • Impact on education
  • Impact on home
  • Impact on activities of daily living
  • Impact on ability to care for others
  • Impact on personal frailty or safety
  • Identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

  • Willingness to have surgery (where surgery is a likely intervention)
  • Choice to be treated as a public or private patient
  • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)
  • Please note that where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service.  Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.

  • A change in patient circumstance (such as condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.

  • Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.