Dizziness/Vertigo

Last updated 31 May 2026 · Neurology / ENT

📋 Key Information Summary

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Dizziness is one of the most common presenting complaints in Australian general practice, accounting for approximately 3–5% of all consultations; it is a symptom, not a diagnosis, and requires systematic characterisation.
Distinguish vertigo (illusion of movement, usually rotational), presyncope (sensation of impending faint), syncope (transient loss of consciousness with spontaneous recovery), and nonspecific dizziness (lightheadedness, unsteadiness) — the differential diagnosis and urgency differ markedly between categories.
Peripheral vertigo (vestibular origin) is typically abrupt, severe, and episodic with nausea/vomiting, worsened by head movement, and associated with horizontal nystagmus that follows Alexander's law and suppresses with visual fixation; cranial nerve examination is normal.
Central vertigo (brainstem/cerebellar origin) is often gradual in onset, less severe but persistent, may be accompanied by diplopia, dysarthria, ataxia, or focal neurological signs, and nystagmus may be vertical, bidirectional, or unsuppressed by fixation — this warrants urgent neuroimaging.
Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause of vertigo overall (~20–30% of presentations); posterior canal BPPV accounts for ~85% of cases and is diagnosed by a positive Dix-Hallpike manoeuvre; the Epley canalith repositioning manoeuvre is first-line treatment with a single-session cure rate of approximately 80%.
Ménière disease presents with the triad of episodic vertigo (20 minutes to 12 hours), fluctuating sensorineural hearing loss, tinnitus, and aural fullness; it is managed with dietary sodium restriction (<2 g/day), betahistine (off-label in Australia), vestibular rehabilitation, and specialist referral for refractory cases.
Acoustic neuroma (vestibular schwannoma) presents with progressive unilateral sensorineural hearing loss, tinnitus, and mild imbalance; gadolinium-enhanced MRI is the gold-standard investigation; management ranges from observation ("watch and wait") to stereotactic radiosurgery or microsurgery.
In the elderly, dizziness is frequently multifactorial — polypharmacy, orthostatic hypotension, vestibular hypofunction, visual impairment, cervical proprioceptive loss, and peripheral neuropathy all contribute; a falls risk assessment (using the Falls Risk Assessment Tool or Timed Up and Go test) is mandatory.
Red flags requiring emergency referral include new-onset vertigo with any focal neurological deficit, severe headache ("thunderclap"), acute hearing loss, suspected posterior circulation stroke (HINTS positive), or vertigo with cardiovascular risk factors and syncope.
The HINTS examination (Head Impulse, Nystagmus, Test of Skew) is more sensitive than early diffusion-weighted MRI for posterior circulation stroke and can be performed at the bedside in acute vestibular presentations.
Aboriginal and Torres Strait Islander Australians experience higher rates of chronic ear disease and hearing loss, which may contribute to vestibular dysfunction; culturally safe assessment, access to specialist services in rural and remote communities, and awareness of otitis media burden are essential.

Introduction & Australian Epidemiology

Dizziness is among the most frequent presenting complaints across Australian general practice and emergency departments, accounting for an estimated 3–5% of all primary care consultations and up to 4% of emergency presentations nationally. The prevalence increases sharply with age — community studies report that up to 30% of adults over 65 years experience dizziness, and it is the single most common complaint in those over 75 years. Dizziness is not a diagnosis but a symptom encompassing a broad differential that ranges from benign self-limiting conditions to life-threatening vascular events.

A structured diagnostic approach is essential. The first step is to determine what the patient means by dizziness — whether the sensation is one of vertigo (spinning or movement), presyncope (feeling faint), syncope (transient loss of consciousness), or nonspecific lightheadedness and unsteadiness. This characterisation dramatically narrows the differential and directs subsequent investigation and management.

In Australia, the annual incidence of BPPV is estimated at 1.6% of the adult population, making it the single most common vestibular disorder. Ménière disease affects approximately 0.2% of the population. Vestibular neuritis and labyrinthitis account for a further 5–10% of vertigo presentations. Central causes — particularly posterior circulation ischaemic stroke — must always be considered, especially in patients with cardiovascular risk factors, and are estimated to underlie approximately 3–5% of acute vertigo presentations to emergency departments.

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Posterior circulation stroke can masquerade as peripheral vertigo. Up to 10% of patients initially diagnosed with a peripheral vestibular event in the emergency department are subsequently found to have a cerebellar or brainstem infarction. The HINTS examination should be performed in all acute continuous vertigo presentations to improve diagnostic accuracy beyond early MRI.

Defined Terminology

Precise characterisation of the patient's dizziness is the single most important diagnostic step. The traditional "dizziness" categorisation (Type I–IV) has been replaced by a symptom-based approach that maps more reliably to underlying aetiology.

Symptom	Description	Likely Mechanism	Key Differentials
Vertigo	Illusory sensation of rotation or movement of self or environment; often worse with head position change	Vestibular (peripheral or central) asymmetry	BPPV, vestibular neuritis, Ménière disease, posterior circulation stroke, vestibular migraine
Presyncope	Sensation of impending faint; lightheadedness, visual greying, muffled hearing, feeling warm	Global cerebral hypoperfusion	Orthostatic hypotension, vasovagal episode, cardiac arrhythmia, aortic stenosis, medication effect
Syncope	Transient loss of consciousness with complete spontaneous recovery; usually due to global cerebral hypoperfusion	Acute global cerebral hypoperfusion	Vasovagal, orthostatic, cardiac (arrhythmic, structural), situational
Nonspecific dizziness	Lightheadedness, floating, heavy-headed, vague unsteadiness without true vertigo or presyncope	Multifactorial; often vestibular, psychological, metabolic, or medication-related	Persistent postural-perceptual dizziness (PPPD), anxiety/panic disorder, medication side effects, deconditioning, vestibular hypofunction

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Clinical pearl: Studies show that up to 50% of patients cannot reliably categorise their dizziness into the traditional four types using closed-ended questions. Open-ended questioning ("Can you describe exactly what happens when you feel dizzy?"), supplemented by observing the patient's gestures (a spinning motion vs swaying vs vague hand-wave), yields more accurate classification.

Peripheral vs Central Vertigo

Distinguishing peripheral from central vertigo is the critical diagnostic branch point. Peripheral causes arise from the inner ear (labyrinth) or vestibular nerve; central causes arise from the brainstem vestibular nuclei or cerebellum. While peripheral causes are far more common (>80% of presentations), central causes carry significantly greater morbidity and mortality, particularly posterior circulation stroke.

Feature	Peripheral Vertigo	Central Vertigo
Onset	Often sudden and severe	Often gradual or subacute; may be acute (stroke)
Duration	Episodic: seconds (BPPV), minutes (TIA), hours (Ménière), days (neuritis)	Persistent or prolonged; may be continuous for days
Severity of vertigo	Intense; often disabling	Mild to moderate (patients may appear surprisingly well)
Nystagmus	Horizontal-torsional; follows Alexander's law (beats faster when looking toward fast phase); suppresses with visual fixation	Vertical, purely torsional, or bidirectional; does NOT suppress with fixation; may change direction with gaze
Head impulse test	Abnormal (corrective saccade — "catch-up" movement of the eyes)	Normal (no corrective saccade)
Test of skew	Negative (no vertical ocular misalignment)	Positive (vertical correction when covering/uncovering one eye)
Hearing loss / tinnitus	Often present (except vestibular neuritis)	Rare (except AICA territory stroke)
Focal neurological signs	Absent	Often present — diplopia, dysarthria, dysphagia, limb ataxia, hemisensory loss
Nausea / vomiting	Often severe	Variable; may be mild
Visual fixation effect	Reduces nystagmus and symptoms	No significant effect

The HINTS Examination (Head Impulse – Nystagmus – Test of Skew)

The HINTS battery is the most important bedside examination in acute vestibular syndrome (continuous vertigo lasting >24 hours). It has been shown to be more sensitive than early diffusion-weighted MRI for posterior circulation stroke in the first 48 hours.

Head Impulse Test

With the patient fixating on your nose, rotate the head rapidly 15–20° to one side. A corrective "catch-up" saccade to re-fixate indicates a peripheral lesion on the side of head turn. A normal head impulse in a vertiginous patient is concerning for stroke.

Nystagmus

Observe nystagmus in primary gaze, right gaze, and left gaze. Purely horizontal or horizontal-torsional nystagmus that follows Alexander's law is peripheral. Vertical or bidirectional nystagmus is central.

Test of Skew

Alternately cover and uncover each eye. Vertical correction (one eye appears to shift up or down) suggests a central lesion. A positive test of skew is highly specific for central vertigo.

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HINTS = stroke rule: Any ONE of the following in a patient with acute continuous vertigo is a positive HINTS screen for central vertigo: (1) normal head impulse test, (2) direction-changing nystagmus, or (3) positive test of skew. These patients require urgent neuroimaging and neurology/stroke unit referral, even if initial CT brain is normal.

BPPV, Ménière Disease & Acoustic Neuroma

Benign Paroxysmal Positional Vertigo (BPPV)

BPPV is the single most common vestibular disorder, accounting for 20–30% of all vertigo presentations. It results from displaced otoconia (calcium carbonate crystals from the utricular macule) that migrate into the semicircular canals — most commonly the posterior canal (~85%), less commonly the horizontal (lateral) canal (~10–15%), and rarely the anterior canal (~1–2%).

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Pathognomonic presentation: Brief (<60 seconds) episodes of rotational vertigo provoked by specific head position changes — rolling over in bed, looking up (cabinet manoeuvre), bending forward, or lying back. No associated hearing loss, tinnitus, or neurological symptoms. There is a latency of 1–5 seconds between the provocative position and onset of vertigo, with a crescendo–decrescendo pattern and fatiguability on repetition.

Diagnosis

Dix-Hallpike manoeuvre (posterior canal BPPV): The patient sits on the examination table, head rotated 45° to the tested side, then is rapidly reclined with the head hanging 20° below horizontal. Observe for torsional-upbeating nystagmus with a latency of 1–5 seconds, lasting <60 seconds, with fatiguability on repeat testing.

Supine roll test (horizontal canal BPPV): Patient supine, head elevated 30°, rapidly rotate head to each side. Horizontal (geotropic or apogeotropic) nystagmus lasting >60 seconds suggests horizontal canal involvement.

Treatment

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Epley Canalith Repositioning Manoeuvre

Posterior canal BPPV — first-line treatment

Technique From the positive Dix-Hallpike position, rotate head 90° to the opposite side, then rotate the patient 90° further so they lie on the opposite shoulder, then sit upright. Hold each position for 30–60 seconds or until nystagmus resolves.

Efficacy Single-session resolution in ~80%; up to 95% after 2–3 sessions

Post-procedure Sleep semi-recumbent (45°) for 2 nights; avoid head below horizontal for 48 hours

PBS status N/A — procedural, no PBS listing

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Semont (liberatory) manoeuvre

Alternative for posterior canal BPPV

Technique From sitting, rapidly lay the patient onto the affected side (ear down), hold 30 seconds, then rapidly swing through to the opposite side (ear up), hold 30 seconds, then sit up.

Efficacy Comparable to Epley; preferred by some practitioners for simplicity

PBS status N/A — procedural, no PBS listing

Horizontal canal BPPV is treated with the Lempert (barbecue) roll manoeuvre (patient rotated 360° in 90° increments toward the unaffected side while prone) or the Gufoni manoeuvre. Vestibular suppressant medications are not recommended as primary treatment for BPPV and may delay recovery.

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Vestibular suppressants (e.g., prochlorperazine, meclizine, dimenhydrinate) should NOT be used as ongoing treatment for BPPV. They do not treat the underlying mechanism (canalithiasis) and may impair central vestibular compensation. If nausea is severe, a single dose of ondansetron 4 mg ODT prior to the repositioning manoeuvre may be considered.

Ménière Disease

Ménière disease is a chronic inner ear disorder characterised by episodic vertigo, fluctuating sensorineural hearing loss, tinnitus, and aural fullness. It results from endolymphatic hydrops (excess endolymph in the membranous labyrinth). Diagnosis is clinical and requires at least two spontaneous vertigo attacks lasting 20 minutes to 12 hours, audiometrically documented low-to-medium frequency sensorineural hearing loss on at least one occasion, and associated fluctuating aural symptoms (hearing, tinnitus, or fullness).

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Betahistine

Serc® · Betahistine dihydrochloride · H₁ agonist / H₃ antagonist

Adult dose 16 mg PO TDS (range 8–48 mg TDS); titrate over several weeks

Paediatric dose Not recommended <18 years (insufficient data)

Duration Long-term; reassess at 3–6 months for clinical response

Renal / Hepatic No specific dose adjustment; use caution in severe hepatic impairment

PBS status ⚠️ Not PBS listed — private prescription

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Prochlorperazine (acute vertigo)

Stemetil® · Dopamine antagonist / vestibular suppressant

Adult dose 5–10 mg PO/IM/PR every 6–8 hours PRN (acute attacks only); buccal Stemetil 3 mg TDS

Duration Short-term only (≤7 days); prolonged use risks extrapyramidal side effects and tardive dyskinesia

PBS status ✔ PBS General Benefit

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Ondansetron (anti-emetic adjunct)

Zofran® · 5-HT₃ antagonist

Adult dose 4–8 mg PO/IV/ODT every 6–8 hours PRN

Duration Acute episodes only; does not treat underlying vertigo

PBS status ✔ PBS General Benefit

Management of Ménière Disease

Lifestyle Modification

Dietary sodium restriction (<2 g/day), reduce caffeine and alcohol intake, stress management, adequate sleep hygiene, smoking cessation

Pharmacotherapy

Betahistine 16 mg PO TDS (off-label use, not PBS-listed); diuretic therapy (e.g., hydrochlorothiazide 25 mg daily) may be trialled — evidence is limited

Acute Attack Management

Prochlorperazine 5–10 mg IM/PR or buccal 3 mg; ondansetron 4–8 mg ODT; rest in a dark quiet room; intratympanic dexamethasone by ENT specialist

Refractory Disease (specialist)

Intratympanic gentamicin (chemical labyrinthectomy), endolymphatic sac decompression, vestibular neurectomy, or labyrinthectomy (last resort, destroys hearing)

Acoustic Neuroma (Vestibular Schwannoma)

Acoustic neuromas are benign, slow-growing Schwann cell tumours arising from the vestibular portion of cranial nerve VIII at the cerebellopontine angle. They account for approximately 6–8% of all intracranial tumours. Bilateral acoustic neuromas are pathognomonic of Neurofibromatosis Type 2 (NF2), which should be considered in any patient presenting before age 30 or with bilateral tumours.

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Unilateral sensorineural hearing loss — particularly asymmetrical or progressive — warrants investigation for acoustic neuroma. Up to 10% of patients with sudden sensorineural hearing loss will have an acoustic neuroma identified on MRI. Any unexplained unilateral hearing loss should prompt referral for MRI with gadolinium.

Clinical Features

Unilateral progressive sensorineural hearing loss (most common presenting symptom, ~95%)
Unilateral tinnitus (~60–70%)
Mild disequilibrium rather than true vertigo (the slow growth allows central compensation)
Facial nerve compression → facial numbness, weakness (late, CN V and VII)
Large tumours (>3 cm): hydrocephalus, brainstem compression, cerebellar ataxia

Investigation & Management

MRI brain with gadolinium is the gold-standard investigation (sensitivity >99%). Pure tone audiometry and speech discrimination testing are essential baseline assessments. Management is guided by tumour size, symptom burden, patient age, and comorbidities:

Observation ("watch and wait") — Serial MRI at 6-monthly then annual intervals. Appropriate for small tumours (<1 cm), elderly patients, or those with significant comorbidities. Approximately 40–60% of tumours show no significant growth over 5 years.
Stereotactic radiosurgery (Gamma Knife or CyberKnife) — Suitable for tumours ≤3 cm with serviceable hearing. Tumour control rate >90% at 10 years. Available at major tertiary centres in Australia (e.g., Royal Prince Alfred Hospital, Peter MacCallum Cancer Centre).
Microsurgery (retrosigmoid or translabyrinthine approach) — Preferred for large tumours (>3 cm), those causing brainstem compression, or younger patients where long-term radiation effects are a concern. Available at major neurosurgical centres nationally.

All patients with acoustic neuroma should be managed by a multidisciplinary team including ENT/neurotology, neurosurgery, audiology, and radiation oncology.

Office Tests & Dizziness in the Elderly

Bedside / Office Assessment

A structured bedside assessment can identify the cause of dizziness in the majority of cases. The following should be performed in every dizzy patient:

Essential Detailed history Character (vertigo vs presyncope vs nonspecific), duration (seconds/minutes/hours/days), triggers (positional, spontaneous, exertional), associated symptoms (hearing loss, tinnitus, headache, nausea, neurological symptoms), medications (antihypertensives, sedatives, aminoglycosides), and cardiovascular risk factors.

Essential Vital signs Blood pressure (lying and standing — diagnosis of orthostatic hypotension if SBP drops ≥20 mmHg or DBP drops ≥10 mmHg within 3 minutes of standing), heart rate and rhythm.

Essential Otoscopy Exclude acute otitis media, cholesteatoma, middle ear effusion, vesicles (Ramsay Hunt syndrome), or cerumen impaction.

Essential Dix-Hallpike manoeuvre Gold standard for posterior canal BPPV. Perform bilaterally. Positive test → torsional-upbeating nystagmus with latency and fatiguability.

Available HINTS examination Head impulse, nystagmus direction, test of skew — for acute continuous vertigo to differentiate peripheral from central causes. More sensitive than early MRI for posterior circulation stroke.

Available Finger-to-nose and heel-to-shin testing Assess for cerebellar dysmetria and limb ataxia — if present, suspect central vertigo and refer urgently.

Available Romberg test and gait assessment Unsteady gait with eyes open suggests significant vestibular or cerebellar dysfunction. Assess with Timed Up and Go (TUG) test in elderly patients (>12 seconds is abnormal).

Available Tuning fork tests (Rinne & Weber) 512 Hz fork: Weber lateralises to the better ear in sensorineural hearing loss (toward worse ear in conductive). Rinne: air conduction > bone conduction normally; if bone > air, conductive loss is present.

Specialist Audiometry Pure tone and speech audiometry — required for Ménière disease evaluation, acoustic neuroma screening, and any unexplained hearing loss. Available MBS item 82200.

Specialist Videonystagmography (VNG) / caloric testing Objective assessment of vestibular function — quantifies unilateral vestibular hypofunction. Performed by ENT or vestibular physiotherapy services.

Investigations for Dizziness in General Practice

Routine blood tests are rarely diagnostic in isolated dizziness but may reveal contributory factors:

FBC — anaemia, polycythaemia
Electrolytes, glucose, calcium — metabolic causes
TFTs — hypo/hyperthyroidism
ECG — arrhythmia, prolonged QTc, heart block (mandatory if presyncope/syncope suspected)
CT brain (non-contrast) — if central vertigo suspected and MRI not immediately available; sensitivity for posterior fossa stroke is low (~16% in first 24 hours)
MRI brain with gadolinium — gold standard for acoustic neuroma and posterior fossa pathology; should be requested for any suspected central vertigo or unexplained unilateral sensorineural hearing loss

Dizziness in the Elderly

Dizziness is the most common complaint in adults over 75 years and is an independent risk factor for falls, which are the leading cause of injury-related hospitalisation and death in older Australians. Dizziness in the elderly is almost always multifactorial, requiring a comprehensive geriatric assessment approach rather than a single-diagnosis hunt.

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Falls prevention: All elderly patients presenting with dizziness should have a falls risk assessment. In Australia, the Royal Australian College of General Practitioners (RACGP) recommends using the Timed Up and Go (TUG) test or the Falls Risk for Older People — Community Setting (FROP-Com) tool. A TUG time >12 seconds indicates elevated falls risk. Referral to a falls prevention programme is recommended for high-risk patients.

Contributing Factor	Assessment / Action
Polypharmacy	Medication review — benzodiazepines, antihypertensives (especially alpha-blockers, loop diuretics), anticonvulsants, aminoglycosides, antidepressants, and opioids all contribute. Aim for deprescribing where safe.
Orthostatic hypotension	Measure BP lying and standing (after 1 min and 3 min). Diagnose if SBP drop ≥20 mmHg or DBP drop ≥10 mmHg. Review fluid intake, salt intake, medications, and consider fludrocortisone or midodrine if persistent.
Bilateral vestibular hypofunction	Common in the elderly due to cumulative vestibular damage; presents as oscillopsia with head movement and unsteadiness in darkness. Romberg with eyes closed is positive. Vestibular rehabilitation therapy is first-line.
BPPV	Still the most common vestibular cause in the elderly; Dix-Hallpike manoeuvre and Epley manoeuvre should be performed (modified positioning if cervical pathology present). Recurrence rate is higher in the elderly (~30–50% per year).
Visual impairment	Visual acuity assessment; refer for optometry review. Cataracts, macular degeneration, and refractive errors impair spatial orientation and postural stability.
Cervical proprioceptive loss	Cervical spondylosis can impair proprioceptive input; assess cervical range of motion and consider physiotherapy referral.
Peripheral neuropathy	Assess ankle proprioception and vibration sense; common in diabetes. Contributes to unsteadiness and falls.
Cardiac causes	ECG mandatory; consider Holter monitor, echocardiography if presyncope/syncope component. Arrhythmias and valvular disease are more common in the elderly and may present as "dizziness."

Vestibular Rehabilitation Therapy

Vestibular rehabilitation therapy (VRT) is an evidence-based exercise programme that promotes central vestibular compensation. It is indicated for persistent dizziness following vestibular neuritis, bilateral vestibular hypofunction, and chronic subjective dizziness / PPPD. In Australia, VRT is delivered by physiotherapists with vestibular training, available through public hospital outpatient departments and private practice (MBS item 10960 — referred attendance). A Cochrane systematic review confirms VRT is superior to placebo for both peripheral and central vestibular disorders.

Special Populations

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Pregnancy

BPPV

Most common vestibular cause in pregnancy; Dix-Hallpike and Epley manoeuvres are safe at all gestational ages. Left lateral positioning may be preferred in late pregnancy for maternal comfort.

Vestibular suppressants

Prochlorperazine is Category B1 (may be used with caution); promethazine is Category C; meclizine and dimenhydrinate have limited safety data in pregnancy — discuss risk-benefit with patient.

Ménière disease

May worsen during pregnancy due to fluid retention; sodium restriction and betahistine should be discussed with the treating obstetrician. Betahistine is not recommended in pregnancy due to insufficient data.

Vertebrobasilar insufficiency

Hypercoagulable state increases stroke risk; maintain high suspicion for central vertigo with any focal neurological signs. CT with lead shielding or MRI (no gadolinium) are the preferred imaging modalities.

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Paediatrics

Common causes

Vestibular migraine is the most common cause of vertigo in children (prevalence ~2–3%). BPPV is rare in children but can occur post-head trauma. Benign paroxysmal vertigo of childhood (BPVC) is a migraine precursor that resolves spontaneously by age 8–10.

Otitis media

Very common in Australian children, particularly Aboriginal and Torres Strait Islander children; acute otitis media with inner ear extension can cause vertigo and hearing loss. Treat with amoxicillin 45–50 mg/kg/day PO BD–TDS for 5–7 days per eTG.

Assessment challenges

Young children cannot describe vertigo; parents may report episodes of crying, unsteadiness, or clutching onto objects. Modified Dix-Hallpike can be performed in children who can cooperate; otherwise, referral to paediatric ENT.

Medications

Most vestibular suppressants are not recommended in children <2 years (risk of respiratory depression). Ondansetron 0.1–0.15 mg/kg PO/IV (max 4 mg) is safe for nausea. Avoid prochlorperazine in children.

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Renal Impairment

Betahistine

No specific dose adjustment required; however, use caution in severe renal impairment (eGFR <15 mL/min) due to limited data.

Prochlorperazine

No dose adjustment required for renal impairment; however, increased risk of extrapyramidal side effects in uraemic patients — use lowest effective dose for shortest duration.

Aminoglycoside ototoxicity

Patients on aminoglycosides with renal impairment are at significantly elevated risk of vestibular and cochlear toxicity; therapeutic drug monitoring is essential. Avoid concurrent loop diuretics where possible.

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Hepatic Impairment

Prochlorperazine

Use with caution in severe hepatic impairment; impaired metabolism may prolong effects and increase risk of extrapyramidal side effects.

Betahistine

No specific dose adjustment; limited data in severe hepatic impairment — use clinical judgment.

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Immunocompromised

Labyrinthitis

Immunocompromised patients (HIV, transplant recipients, chemotherapy) are at increased risk of viral (CMV, HSV) and bacterial labyrinthitis. Consider broad-spectrum investigation including MRI and CSF analysis if presentation is atypical.

Meningogenic spread

Bacterial meningitis can cause sensorineural hearing loss and vestibular dysfunction; immunocompromised patients with meningitis should have audiological follow-up arranged post-treatment.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Australians experience disproportionately higher rates of ear disease, hearing loss, and vestibular dysfunction compared to the non-Indigenous population. Otitis media (OM) — including chronic suppurative otitis media (CSOM) and otitis media with effusion (OME) — is one of the most significant health burdens in Indigenous communities, particularly in remote and very remote areas of northern and central Australia. The prevalence of CSOM in some remote Aboriginal communities has been reported as high as 15–40% of children, compared with <1% in the general Australian population. This chronic ear disease burden directly contributes to sensorineural and conductive hearing loss, which in turn affects vestibular function, balance, and falls risk.

Ear disease burden

Otitis media affects up to 90% of Aboriginal and Torres Strait Islander children in some remote communities before age 12 months. CSOM is 6–7 times more prevalent than in non-Indigenous Australians. Chronic ear disease can lead to permanent sensorineural hearing loss and vestibular impairment. The Deadly Ears programme (Queensland) and the Northern Territory Otitis Media Guidelines provide region-specific management pathways.

Hearing loss & vestibular function

Sensorineural hearing loss in the setting of chronic ear disease may co-exist with vestibular dysfunction. Patients may describe "unsteadiness" rather than vertigo, which may be attributed to hearing loss alone. Clinicians should actively assess for vestibular symptoms and perform bedside vestibular testing (Dix-Hallpike, Romberg, gait assessment) in any Indigenous patient with chronic ear disease and reported dizziness.

Access to specialist services

Access to ENT, audiology, and vestibular specialist services is severely limited in remote and very remote Indigenous communities. The visiting specialist model (through organisations such as the Australian Government's Medical Specialist Outreach Assistance Program — MSOAP) and tele-ENT services help bridge this gap, but long wait times remain a significant barrier. Patients may need to travel hundreds of kilometres to access definitive assessment and management.

Falls prevention

Aboriginal and Torres Strait Islander adults experience higher rates of falls-related injury and hospitalisation. The relationship between chronic ear disease, vestibular dysfunction, and falls risk is under-recognised. Community-based falls prevention programmes should incorporate vestibular assessment and hearing screening. Coordinate with local Aboriginal Community Controlled Health Organisations (ACCHOs) for culturally safe delivery.

Cultural safety

Provide culturally safe care by: using interpreters (Aboriginal and Torres Strait Islander language speakers) when English is not the patient's first language; involving Aboriginal and Torres Strait Islander health workers in consultations; understanding the patient's health beliefs regarding ear disease and balance; using the RACGP's National Guide to a Preventive Health Assessment for Aboriginal and Torres Strait Islander People (3rd edition) as a screening framework.

Prevention & health promotion

Promote the "ear health" message through locally designed health promotion materials. Advocate for housing improvements (overcrowding is a key risk factor for OM transmission), smoking cessation (maternal smoking increases OM risk), and timely management of upper respiratory tract infections. Support community-led programmes such as Deadly Ears (Qld), Healthy Ears (NT), and the Telethon Kids Institute's ear health research programme in the Kimberley.

📚 References

1. Royal Australian College of General Practitioners (RACGP). Guidelines for Preventive Activities in General Practice (Red Book). 9th edn. Melbourne: RACGP; 2016 (updated 2023). Chapter: Falls prevention in older people.
2. Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical practice guideline: benign paroxysmal positional vertigo (update). Otolaryngol Head Neck Surg. 2017;156(3_suppl):S1–S47.
3. Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009;40(11):3504–3510.
4. Lopez-Escamez JA, Carey J, Chung WH, et al. Diagnostic criteria for Ménière's disease. J Vestib Res. 2015;25(1):1–7.
5. National Health and Medical Research Council (NHMRC). Clinical Practice Guideline: Otitis Media (Acute) — Management of Acute Otitis Media in Children. Canberra: NHMRC; 2014.
6. The Royal Australian and New Zealand College of Ophthalmologists; Australasian Society of Clinical Immunology and Allergy (ASCIA). Vestibular schwannoma (acoustic neuroma): evaluation and management. Aust Fam Physician. 2018;47(4):202–206.
7. Australian Institute of Health and Welfare (AIHW). Ear Disease in Aboriginal and Torres Strait Islander Children. Cat. no. IHW 222. Canberra: AIHW; 2020.
8. McDonnell MN, Hillier SL. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev. 2015;(1):CD005397.
9. Healthdirect Australia. Dizziness and vertigo: assessment and management. Healthdirect.gov.au. Sydney: Healthdirect Australia; 2023. Available at: https://www.healthdirect.gov.au/dizziness-and-vertigo.
10. Royal Australian College of General Practitioners (RACGP). National Guide to a Preventive Health Assessment for Aboriginal and Torres Strait Islander People. 3rd edn. Melbourne: RACGP; 2018.
11. Newman-Toker DE, Edlow JA. TiTrATE: a novel, evidence-based approach to diagnosing acute dizziness and vertigo. Neurol Clin. 2015;33(3):577–599.
12. Department of Health and Aged Care (Australian Government). Deadly Ears Program: Aboriginal and Torres Strait Islander Ear Health. Canberra: Commonwealth of Australia; 2022. Available at: https://www.health.gov.au/.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).