Patient Pathways: ENT

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1 Patient Pathways: ENT Evidence Table: Dizziness Author Year Study type Population Summary of Paper Comments Colledge 1996 Cohort study Community based elderly >65 years UK 149 dizzy 97 control Self-selected Aim: identify appropriate investigations Outcome measures: Findings on physical examination, bloods, ECG, electronystagmography, posturography, and MRI of head and neck, depression score, anxiety score, hyperventilation, carotid sinus massage and Hallpike manoeuvre. Results: Posturography and clinical assessment were found to be the most relevant. Most common diagnosis central vascular disease cervical spondylosis often accompanied by poor vision and anxiety. Conclusion: Expensive investigations rarely helpful in dizzy elderly people. Diagnosis can be made in most cases on the basis of a thorough clinical examination without hospital referral and can be performed by a practice nurse. Has a section on advice for GPs and Diagnostic criteria for causes of dizziness. Authors acknowledge bias inevitable - very frail elderly may have felt unable to participate, those more concerned about their symptoms may have been more likely to volunteer. Control group may have been fitter than average for age but no different from dizzy subjects in age and functional ability. Algorithm for evaluation of cause of dizziness in elderly patients in general practice Appendix 1. Lawson 1999 Case control study prospective 50 consecutive patients > 60 yrs & 22 age/sex matched case controls from same GP practices UK Purpose: Identify causes of dizziness and guide the GP to the most appropriate specialty for referral if required. Measurements: Diagnosis based on symptoms Conclusion: Presenting clinical characteristics can predict an attributable cause of dizziness in most older patients. Majority of older patients referred with dizziness had underlying central neurological disorder or cardiovascular cause for symptoms and yet most refer to ENT clinics. Therefore guidance can be developed for more appropriate referral for further cardiovascular or neurological assessment particularly if syncope, unexplained falls or injury are occurring. 3/12 recruitment period. All patients referred randomly for investigations to either Neurocardiovascular Investigation Unit or ENT Department in secondary care. Referral criteria not included in paper. Authors feel that GPs had only enrolled patients with severe dizziness or additional disabling symptoms - according to a US survey there should have been approx. double the number of patients recruited. No means of checking referral practice was built into the study protocol.

2 PRODIGY NHS Last revised Oct 2001 On-line guidance for GPs Evidence based For use by NHS staff - guidance for management of patients over 16 years Meniere s Disease Covers: definition, symptoms, diagnosis, management, medication, indications for surgery, balance training. Meniere s Disease Scenario therapy, prescribing, follow-up, investigations, referral, patient information. Edmeads 1990 Personal opinion Canada Understanding Dizziness How to decipher this non-specific symptom Primary care physicians can in majority of cases decipher symptoms and determine the cause of dizziness based on patient history and physical examination. Discusses in detail causes and offers management options. 4 broad categories normal bodily sensations ; hyperventilation ; presyncope ; vertigo. Kentala 2003 Prospective blinded study 57 Patients at tertiary referral neurology practice USA Finland A practical assessment algorithm for diagnosis of dizziness Evaluation of model for diagnosis of dizziness. Method : patients completed a pre-examination questionnaire - reporting type and timing of dizziness symptoms and hearing status this enabled the patient to classify their own dizziness into 1 of 4 categories: Near Syncope ; Dysequilibrium ; True Vertigo and Psychogenic dizziness. One of 4 diagnoses (Benign Paroxysmal Positional Vertigo [BPPV] ; Meniere s Disease ; vestibular neuritis ; labyrinthitis) could then be given using the diagnostic algorithm matrix. Results: Diagnosis confirmed by otologist who used patient history, physical exam and results of audiometric and oto-neurologic tests to make diagnosis - 60% of patients who had a common otogenic cause of vertigo were correctly classified using the diagnostic algorithm matrix the remainder had migraine associated dizziness or a variety of other peripheral, central or undiagnosed abnormalities. Conclusion: this classification scheme is as good as others of much greater complexity. It is based on history alone and facilitates triage of dizzy patients into diagnostic groups for work-up and management. Appendix 2 excerpts from guideline Bibliography listed Appendix 3 4 step approach to evaluate dizziness summarised version may be of use in pathway development. Referenced. Appendix 4 Diagnostic algorithm matrix Appendix 5 triage/referral excerpt from paper Appendix 6 Dizziness questionnaire Oversimplification of the matrix leads to misclassifications by excluding some patients who have 1 of 4 common diagnosis but have symptoms that deviate from the most common pattern. The matrix is not well suited to patients with multiple dizziness diagnoses as only 1 choice allowed. Confounding symptoms caused some confusion with patients resulting in misclassification. It does however allow rapid and reasonably accurate triage of dizzy patients into diagnostic groups for further management.

3 Bird 1998 General review 503 patients from 3 x GP practices over 2 year period. UK An analysis of referral patterns for dizziness in the primary care setting Comparison of current practice against set local criteria. Referrals audited according to appropriateness of decision to refer - 17% failed, based on decision to refer ; unnecessary referrals ; delayed referral or referral to inappropriate specialty. Conclusion: These problems with referral result in patients (particularly elderly) being under referred and therefore not having access to appropriate treatment regimes. Criteria development fully evidence based outline of development process documented includes systematic Medline searches. Criteria any case of suspected serious cardiac or neurological disorder should be referred immediately or routine referral if - greater or equal to 3 acute attacks lasting for greater than 6 weeks and resisting treatment Where to refer depends on associated symptoms past medical history and nature of symptoms. Cook 2001 General review and audit findings UK The case for a one-stop balance centre Vertigo, imbalance and dizziness Covers: causes ; diagnostic issues ; referral patterns Audit results: on average dizzy patients would see 5 physicians before treatment multiple investigations often organised.?necessary and typical interval from 1 st GP visit to receiving treatment could be up to 3 years. Leicester Balance Centre - adopted a US model of single visit balance centres that has shown savings in finance and morbidity. Key Points: Imbalance, vertigo and dizziness are extremely common symptoms and are often poorly understood. Vestibular dysfunction is the main cause and can be successfully treated. The availability of a customized vestibular rehabilitation programme is the cornerstone to successful treatment. The single visit approach to imbalance offers both healthcare benefits and cost savings. A multidisciplinary approach is essential References listed Balance Centre The centre is partially self funding as it treats both NHS and private patients. A vestibular physiotherapist carries out monthly follow-ups till symptoms resolved. Telephone support for patients has helped reduce follow-up visits. Increased training is required for technicians from hearing services and medical physics departments.

4 Ruckenstein 1995 General review USA A practical approach to dizziness Stepwise method of evaluating dizziness provides an in-depth overview of diagnosing different types of Vertigo and Non-vertiginous dizziness in primary care to ensure appropriate investigations are performed in primary care or that appropriate secondary care referral for confirmation of diagnosis is made. Summary: Evaluation of dizziness largely depends on patient history. Diagnosis can be accurately made in primary care using step by step algorithmic approach: Firstly obtain detailed account of precisely what the patient means by dizziness this helps determine whether the cause is vertigo or another condition such as orthostatic hypotension establishing whether the vertigo is central or peripheral in origin and if peripheral how long the episodes last, further focuses the investigation certain clues on physical examination and appropriate use of diagnostic tests help support the diagnosis referral should be contemplated when significant central disease is suspected and when vertigo of peripheral origin is persistent or atypical. References listed Central vertigo inc. migraines & multiple sclerosis Peripheral vertigo diagnosis dependent on duration of symptoms. But includes Meniere s Disease, Recurrent Vestibulopathy Vestibular neuronitis ; Labyrinthitis ; Cholesteatoma ; Perilymphatic Fistula ; Trauma & Ototoxicity Acoustic Neuroma Waterston 1999 General review Australia Vertigo a practical approach to diagnosis and treatment Covers: diagnosis and management of more common vestibular syndromes :- Benign positional vertigo, migraine, Meniere s Disease, acoustic neuroma, multisensory dizziness. Many conditions can be diagnosed in primary care without the need for referral. Exercise treatment rather than chronic drug use is recommended management for patients with uncompensated vestibular lesions. References listed. Appendix 7 Causes of vertigo, Hallpike manoeuvre and list of suggested investigations Appendix 8 Red flags indicating possible CNS disease ; when to refer information and summary of important points.

5 Koelliker 2002 Guideline Non-evidence based New Mexico Assessing the patient with vertigo: guidelines for diagnosis and referral. Systematic approach vital to exclude serious causes and guide appropriate testing and referral. Discusses causes from benign e.g. vestibular neuritis and benign paroxysmal positional vertigo (BPPV) to immediately life threatening e.g. cerebellar infarct or haemorrhage. Diagnosis nature of nystagmus can help identify the origin ; careful neurologic and otologic examinations including cranial nerve and cerebellar testing as well as Rhomberg test ; check for hearing loss. If neurologic exam positive to abnormality CT scan/mri. Positive Dix-Hallpike most likely to have BPPV and requires canalith repositioning procedure. If negative refer for vestibular and otologic testing. Girardi 1998 General review USA Vestibular Rehabilitation therapy (VRT) for the patient with dizziness and balance disorders. Covers: vestibular anatomy & physiology ; vestibular testing ; assessment methods ; candidates for referral and recommendations for referral. Details vestibular tests and their role in diagnosis these appear very specialised and presumed not for primary care implementation. VRT Method: Therapist directed, patient motivated ; home based exercise protocol detailed throughout paper. BPPV patients benefit most from VRT. Conclusion: The exercises must include vision, head and eye movements and also during the treatment the use of vestibule-suppressive medication should be limited as these delay compensation recovery. Hanley 2001 Systematic review Ireland A systematic review of vertigo in primary care Examines the evidence on which GPs can base clinical diagnosis and management. Most likely conditions that present are: Meniere s Disease, Benign Positional Vertigo and Acute Vestibular Neuronitis ; however vascular incidents and neurological causes such as MS can present. References listed Vestibular rehabilitation and canalith repositioning procedure can be done in primary care. Contraindications: high grade carotid stenosis severe disease cervical spine unstable cardiac disease Appendix 9 Performing the Dix-Hallpike test References listed VRT shown to be highly effective treatment using adaptive/compensatory mechanisms in the brain plus or minus restoration of normal vestibular mechanisms in the inner ear. It is hoped this will extinguish symptoms with exercises which alter the gain of the vestibuleocular reflex (VOR) adaptation, substitution, prediction and other strategies will allow recovery. Appendix 10 - Summary of diagnosis and prognosis for VRT referral N.B. Important practice point : vestibular sedatives not recommended on a prolonged basis for any type of vertigo.

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