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Dizziness/vertigo

ADULT

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


Adult

EAR

  • ENT conditions with associated neurological signs
  • Sudden onset debilitating constant vertigo where the patient is very imbalanced (vestibular neuritis/stroke)
  • Sudden onset facial weakness
  • Barotrauma with sudden onset vertigo 
  • Foreign body
  • Complicated mastoiditis/cholesteatoma or sinusitis (periorbital cellulitis, frontal sinusitis with persistent frontal headache)
  • Ear canal oedema/unable to clear discharge
  • Trauma

NOSE

  • Acute bacterial rhinosinusitis - visual disturbance/signs, neurological signs/frontal swelling/severe unilateral or bilateral headache
  • Acute nasal fracture with septal haematoma
  • Unilateral facial swelling with or without dental sepsis
  • Severe or persistent epistaxis

THROAT

  • Airway compromise- stridor/drooling breathing difficulty/acute or sudden voice change/severe odynophagia
  • Ludwig’s angina
  • Acute tonsillitis with airway obstruction and/or unable to tolerate oral intake and/or uncontrolled fever
  • Tonsillar haemorrhage
  • Acute hoarseness associated with neck trauma or surgery
  • Laryngeal obstruction and/or fracture
  • Pharyngeal/laryngeal foreign body
  • Accidental dislodgement or obstruction of permanent tracheostomy
  • New onset of bleeding or shrinkage of laryngectomy stoma
  • Abscess or haematoma, (e.g. peritonsillar abscess/quinsy, salivary abscess, septal or auricular haematoma, paranasal sinus pyocele) with or without associated cellulitis
  • Profound dysphagia (i.e. inability to manage secretions)
  • Supraglittis

 

Paediatric

 EAR

  • Foreign body
  • Trauma
  • New onset facial nerve palsy
  • 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
  • Otitis externa with uncontrolled pain and/or cellulitis extending beyond the ear canal and/or ear canal is swollen shut
  • Auricular haematoma
  • Any suspicions of the complications of ASOM i.e. Mastoiditis (proptosis of pinna), meningitis etc

NOSE

  • Foreign body (button batteries)
  • Trauma with other associated injuries i.e. other facial fractures e.g. orbit
  • Periorbital cellulitis with or without swelling with or without sinusitis
  • Severe or persistent epistaxis
  • Septal haematoma

THROAT

  • Foreign body (button batteries – inhaled or ingested). if suspicion of button battery immediate emergency review
  • Acutely enlarging neck mass with any associated airway symptoms e.g. stridor, drooling, dysphagia etc
  • Airway compromise: severe stridor/drooling/ breathing difficulty/acute, sudden voice change/ severe odynophagia
  • Trauma
  • Abscess or haematoma (e.g. peritonsillar, parapharyngeal (quinsy), salivary, neck or retropharyngeal abscess)
  • Post-tonsillectomy haemorrhage
  • Hoarseness associated with neck trauma or surgery
  • If new onset hoarse voice and any airway obstructive symptoms  

SLEEP DISORDERED BREATHING/OBSTRUCTIVE SLEEP APNOEA

  • Clinical concern regarding prolonged apnoeas, cyanosis, altered level of consciousness or significant and escalating parental concerns should prompt direct phone contact with the ENT registrar on call to discuss the case and arrange review as clinically appropriate

 

 

 

  • Refer to Healthpathways or local guidelines
  • Exclude central cause of vertigo (cardiac/respiratory)
  • Perform Hallpike test and Head Impulse Test (HIT) to determine likely cause of vertigo
  • If BPPV likely based on symptoms and a positive Hallpike, then treat with canalith repositioning manoeuvre (Epleys or BBQ roll) and consider referral to a physiotherapist/vestibular physiotherapist
  • If HIT positive with acute vertigo, consider vestibular neuritis
  • Consider migraine associated vertigo and if appropriate consider trial of
    • Pizotifen 0.5mg to 1mg orally, at night, up to 3mg daily or
    • Propranalol 40mg orally, 2-3 times daily, up to 320mg or
    • Verapamil (sustained release) 160 or 180mg orally, once daily, up to 320 or 360mg daily
  • Arrange diagnostic audiological assessment and/or vestibular testing
  • Review of current medications
  • Occupational therapy home assessment for falls prevention
  • Consider advice regarding safe driving/licencing

Minimum Referral Criteria

  • Category 1
    (appointment within 30 calendar days)
    • No category 1 criteria
  • Category 2
    (appointment within 90 calendar days)
    • No category 2 criteria
  • Category 3
    (appointment within 365 calendar days)
    • Benign paroxysmal positional vertigo (BPPV) refractory to repeated canalith repositioning manoeuvres (> 3 treatments)
    • Co-morbid vestibular or otological conditions 
    • Patients where particle repositioning is not advised due to limited range of movement in the neck, or due to general mobility issues that cannot be managed by a physiotherapist/ vestibular physiotherapist
    • Symptoms not resolved after seeing vestibular physiotherapist

Please insert the below information and minimum referral criteria into referral

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:
    • onset, duration, frequency and quality
    • functional impact of vertigo
    • any associated otological/neurological symptoms
    • any previous diagnosis of vertigo (attach correspondence)
    • any treatments (medication/other) previously tried, duration of trial and effect
    • any previous investigations/imaging results
    • hearing/balance symptoms
    • past history of middle ear disease/surgery
  • Diagnostic audiology assessment (Highly desirable where available and not cause significant delay)

3. Additional referral information Useful for processing the referral

  • History of any of the following:
    • cardiovascular problems
    • neck problems
    • neurological
    • auto immune conditions
    • eye problems
    • previous head injury

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.

Version: 15
Last updated: 21 December 2018

© State of Queensland (Queensland Health) 2023

Except as permitted under the Copyright Act 1968, no part of this work may be reproduced, communicated or adapted without permission from Queensland Health. To request permission email ip_officer@health.qld.gov.au.

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