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REMEDY : BNSSG referral pathways

Dizziness and Vertigo

Checked: 18-06-2018 by Rob.Adams Next Review: 19-06-2019

Principles of Management

Labyrinthitis and Vestibular Neuritis

Patients with peripheral vestibular disorders such as labyrinthitis or vestibular neuritis typically experience an acute episode of very severe dizziness for 24-72 hours, accompanied by nausea or vomiting.  True vertigo (usually rotatory) lasts for seconds or minutes with head movement.  Symptomology reduces the central compensation over a period of days and weeks, though this may be incomplete.  Following the acute phase, treatment with gaze and balance exercises have reported high success rates with improving central compensation.  These exercises are known as 'vestibular rehabilitation' (VR).  Some patients will benefit from both VR and repositioning techniques. Patients presenting with stable, peripheral vestibular deficit frequently benefit from physical manoeuvres or exercises, and may not necessarily warrant referral to ENT in the first instance.

Benign Paroxysmal Positional Vertigo

One of the most common forms is benign paroxysmal positional vertigo (BPPV), due to movement of calcium carbonate crystals in the semicircular canals.  Patients usually describe true vertigo (illusion of movement) or dizziness with movements such as turning over in bed, or head and neck movements.  Symptoms usually last for a few seconds or up to one minute.  Treatment involves a manoeuvre (such as the canalith repositioning technique or Epley) to move the debris to an appropriate part of the vestibular system.  This is very effective for the majority of patients and can be performed in primary care. See section below for further details and videos.

Meniere's Disease

Meniere's disease is a rare progressive disorder of the inner ear of unknown cause characterized by recurrent acute episodes of vertigo, hearing loss, tinnitus, and a sense of pressure in the ear (aural fullness). Vertigo (causing dizziness, nausea, and vomiting) is often the most prominent symptom.

Other Causes of Dizziness and Vertigo

In addition Clinical Knowledge Summaries have useful advice on management of BPPV and other causes of vertigo.

Referral Guidance

There are 3 clinics at UHB in which patients with balance disorders can be seen:

1. The Direct Access Vertigo Clinic:
This is a direct access clinic that allows for the complete assessment and treatment of patients with a clear peripheral (i.e. inner ear) cause for their symptoms. The clinic is run by audiological scientists with input from an ENT consultant where necessary. Any patient presenting with isolated rotatory vertigo brought on by, or worse with, movement can be referred directly to the balance clinic. This includes:
Benign Paroxysmal Positional Vertigo (BPPV). Typically this is rotatory vertigo lasting 30 – 60 seconds with movements e.g. turning over in bed. Repositioning movements are often effective.
Acute Vestibular Failure (Labyrinthitis). This is acute onset severe vertigo, often with nausea and vomiting, that can last 48-72 hours. Most patients will then compensate over several weeks, and return to normal balance function. Those that do not improve may benefit from targeted vestibular rehabilitation.
Other rotatory vertigo where the diagnosis is unclear but there are no other otological or medical symptoms (see below).

Referrals should be sent to the audiology department via eReferral.

2. The ENT Balance Clinic
This is the default option for patients with balance disorders and is most appropriate for those with vertigo in conjunction with asymmetric or sudden hearing loss, tinnitus, otalgia, otorrhoea, or significant medical co-morbidities. This includes patients with suspected Meniere’s disease or vestibular migraine.

Referrals should be sent to ENT via eReferral

3. The Complex Balance Clinic
This is a multi-disciplinary clinic with an ENT consultant and clinical scientist working together. Patients are referred into this clinic from either the direct access vertigo clinic or the ENT clinic (or following triage of the initial referral). The complex balance clinic is reserved for those with more complicated balance problems e.g. where the diagnosis is unclear, initial treatment has been unsuccessful, or there is a particularly complicated history. Children with imbalance may also be seen in this clinic.
Please note that cardiology/ neurology referral should be considered for patients with primarily cardiovascular or neurological symptoms.
Many thanks for considering the Bristol Balance Clinic for your patient. We welcome feedback or queries about the service.

Referrals are for more complex problems and are therefore triaged by either the direct access vertigo clinic or ENT balance clinic above. This is therefore not available on eReferral.


A weekly clinic is also run at the Audiology Department, Southmead Hospital, Tuesday afternoon 1pm - 5pm.  Referrals should be to audiology via eReferral.

Suitable patients for this clinic include:

  • Patients with BPPV who have not responded to treatment in primary care.

  • Patients with true vertigo (illusion of movement usually initiated by head/neck movement). 

Presentations not suitable for this clinic include:

  • Patients with neurological or cardiovascular signs or symptoms - consider referral to Cardiology or Neurology via e-referral.

  • Patients with hearing loss which is unilateral/asymmetrical or of sudden onset - consider referral to ENT (ear) clinic via e-referral.

  • Patients with  tinnitus associated with spells of vertigo - consider referral to ENT (ear) clinic via e-referral.

  • Patients with ear pain, infection or discharge - consider referral to ENT (ear) clinic via e-referral.

  • Patients with regular acute attacks e.g. classic Meniere's - vomiting, hearing loss, tinnitus, aural pressure, warrant a referral to an ENT consultant (VR may be beneficial, though rehabilitation goals in the long term can be problematic).


Benign Paroxysmal Positional Vertigo (BPPV)

Benign Paroxysmal Positional Vertigo (BPPV) usually presents with vertigo/dizziness on body movements such as turning over in bed or head and neck movements. Symptoms usually last for a few seconds or up to one minute. This condition can often be managed successfully in primary care using the Dix-Hallpike manoeuvre for diagnosis and Epley manoeuvre for treatment (see links below to BMJ videos on YouTube on how to perform these). There is also a quick reference for the Epley manoeuvre.

Dix-Hallpike video

Epley Manoeuvre video

In addition Clinical Knowledge Summaries have useful advice on management of BPPV and other causes of vertigo.