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Inicio Acta Otorrinolaringológica Española Vertigo and Dizziness in Hospital: Attendance, Flow and Characteristics of Patie...
Journal Information
Vol. 69. Issue 4.
Pages 219-225 (July - August 2018)
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Vol. 69. Issue 4.
Pages 219-225 (July - August 2018)
Original article
DOI: 10.1016/j.otoeng.2017.08.011
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Vertigo and Dizziness in Hospital: Attendance, Flow and Characteristics of Patients
Vértigo y mareo en el hospital: frecuentación, flujo y características de los pacientes
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Carmen Bécares Martíneza,
Corresponding author
c.bec.mar@gmail.com

Corresponding author.
, Marta M. Arroyo Domingoa, Aurora López Llamesa, Jaime Marco Algarrab, María M. Morales Suárez-Varelac
a Servicio de Otorrinolaringología, Hospital Universitario de Torrevieja, Torrevieja, Alicante, Spain
b Servicio de Otorrinolaringología, Hospital Clínico Universitario de Valencia, Universidad de Valencia, Valencia, Spain
c Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Unidad de Salud Pública, Higiene y Sanidad Ambiental, Departamento de Medicina Preventiva y Salud Pública, Universidad de Valencia, Valencia, Spain
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Figures (1)
Tables (3)
Table 1. ICD-9 Codes Which Classify Vertigo and Dizziness.
Table 2. Context of Hospital Referrals in 2012.
Table 3. Demographic, Clinical and Administrative Characteristics of the Sample.
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Abstract
Introduction and objectives

Vertigo and dizziness as symptoms are frequent in the population. They are present in a wide range of pathologies and it is usually difficult to make an accurate diagnosis. The general objective of this study is to obtain the information to evaluate vertigo and dizziness in the hospital setting. The specific objectives are: to estimate the burden of these symptoms at the hospital; to study patients’ conditions and to detail the flow of these patients inside the hospital.

Methods

Observational descriptive study. We made a search of the referral proposals made in 2011 and 2012 to the hospital because of vertigo symptoms. The patients’ demographic and clinical characteristics, and the administrative details of the referrals were analysed.

Results

A total of 558 proposals were analysed corresponding to 494 patients. Vertigo accounted for 0.5% of all referrals made from Primary Care to the hospital. Sixty-three percent of the sample were women; the average age was 58 years. Eighty-eight percent of the patients were evaluated by Otorhinolaryngology, 24% by Neurology. Thirty point eight percent consulted on 3 or more occasions for the symptom. Sixteen percent were assessed for psychiatric conditions in the hospital.

Conclusions

Vertigo as a symptom is a significant burden in the hospital setting. The patients who suffer it consult on several occasions and are assessed by different specialties. This implies in some cases an excessive and ineffective flow of patients. In our setting, otorhinolaryngology is the main department to treat vertigo and dizziness patients.

Keywords:
Vertigo
Dizziness
Symptoms
Epidemiology
Referral and consultation
Neurotology
Resumen
Introducción y objetivos

Los síntomas de vértigo y mareo son frecuentes en la población, se presentan como manifestación de un amplio abanico de enfermedades y habitualmente es difícil realizar un diagnóstico de certeza. El objetivo general de este estudio es obtener la información para evaluar estos síntomas en el entorno hospitalario. Los objetivos específicos son: estimar el peso global que representan estos síntomas en las derivaciones al hospital; conocer las características de los pacientes derivados y detallar el flujo de las consultas.

Métodos

Estudio descriptivo observacional. Se buscaron las propuestas de consulta realizadas en 2011 y 2012 al hospital por el síntoma de vértigo. Se analizaron características demográficas y clínicas de los pacientes, y administrativas de las derivaciones.

Resultados

Se analizaron un total de 558 propuestas correspondientes a 494 pacientes. El vértigo supuso el 0,5% del total de las derivaciones realizadas desde Atención Primaria al hospital. El 63% de la muestra han sido mujeres, con una edad media de 58 años. El 88% de los pacientes fue valorado por Otorrinolaringología y el 24% por Neurología. Un 30,8% consultó en 3 o más ocasiones por el síntoma. El 16% fue valorado por enfermedad psiquiátrica en el hospital.

Conclusiones

El vértigo como síntoma supone una carga significativa en el ámbito hospitalario. Los pacientes que lo presentan consultan en múltiples ocasiones y son valorados en distintas especialidades. En ciertos casos, el flujo de pacientes puede resultar excesivamente dinámico e ineficaz. En nuestro entorno, Otorrinolaringología es el principal receptor de pacientes con síntomas de vértigo y mareo.

Palabras clave:
Vértigo
Mareo
Síntomas
Epidemiología
Derivación hospitalaria
Otoneurología
Full Text
Introduction

Vertigo and dizziness are 2 highly frequent reasons for medical consultation, and affect 20%–30% of the general population.1–4 These symptoms have a negative effect on the patient's well-being5 and lead to a large number of hospital referrals.

The epidemiology of vertigo remains an underdeveloped area6 and in our environment we are still unaware of the magnitude of the problem.2,6 One of the difficulties found in published studies is that the patients, and even healthcare professionals, tend to use the terms vertigo and dizziness indistinctly. We could define the vertigo syndrome as the illusory sensation of movement,7,8 but there are also descriptions such as the lack of balance or instability, with their origin stemming from different disorders.

This article analyses one symptom but not diagnosis. In other words, we will study the grouping together of a series of complaints which we will now call vertigo.

Recent studies report the high frequency and impact of vertigo symptoms in the population. Appropriate guidance to diagnosis is a challenge for both primary care practitioners (PC) and other hospital specialists. The commonly imprecise nature of the symptom makes it difficult to reach a final diagnosis and this means that a large number of patients present with it for a long period of time, with many different consultations taking place in several specialties. The financial cost of all this is high and leads to great patient dissatisfaction, not just from diagnostic inaccuracy but also due to the repercussions on their quality of life.7

According to a German epidemiological study,1 the vertigo symptom affects 3 out of every 10 patients moderately to severely and is recurrent in 9 out of every 10, affecting the quality of life in 8 out of 10 patients. One North American study9 concludes that in patients with dizziness, vestibular impairment is not usually accurately studied. This leads to a delay or absence in final diagnosis, delay in initiating effective treatment and a lack of recommendations for improving patient flow.

Although we know that the majority of diseases where vertigo is present are of benign prognosis, they may disable patients physically and psychologically,7 which has great impact on the individual and on public health.8

In our environment, an epidemiological study on this issue would offer us a global and realistic view regarding the vertigo symptom, which could be extrapolated to a national level. It is, undoubtedly, a solid base for working on our patients and for improving their performance at work and their quality of life.

The general aim of this study is to obtain the necessary information which allows us to assess the symptom of vertigo in a hospital setting.

Our specific objectives are to:

  • 1)

    Calculate the overall importance of vertigo and dizziness in hospital referrals.

  • 2)

    Determine the characteristics of referred patients.

  • 3)

    Detail the flow of consultations from patients with vertigo and dizziness.

Methods

There is an observational, descriptive, transversal study with data collection from a retrospective cohort, during the period between January 2011 and December 2012 (24 months). Data collection ended in July 2015, with minimum follow-up of 2 and half years.

External consultation proposals made in the hospital from symptoms of vertigo and dizziness were included, from any speciality, including family and community medicine, to any hospital speciality. Those which were coded in accordance with the ninth review of the International Classification of Diseases were selected (ICD-9),10 with the codes belonging to category 386 (syndrome of vertigo and other vestibular changes), code 780.4 (Vertigo and dizziness), the category 780 (badly defined symptoms, signs and states) and code 078.81 (epidemic vertigo). The ICD-9 categories and codes used are specified in Table 1.

Table 1.

ICD-9 Codes Which Classify Vertigo and Dizziness.

386 Syndrome of vertigo and other vestibular disorders 
386.0 Ménière's disease=Endolymphatic hydrops=Lermoyez's syndrome=Ménière's syndrome or vertigo 
386.00 Unspecified Ménière's disease 
386.01 Active cochlevovestibular Ménière's disease 
386.02 Active cochlear Ménière's disease 
386.03 Active vestibular Ménière's disease 
386.04 Inactive Ménière's disease 
 
386.1 Other peripheral vertigo and unspecified peripherical vertigo 
386.10 Unspecified peripheral vertigo 
386.11 Benign paroxysmal positional vertigo=Benign paroxysmal positional nystagmus 
386.12 Vestibular neuronitis=acute peripheral vestibulopathy (and recurrent) 
386.19 Others=aural vertigo=orthogenic 
 
386.2 Central nerve origin vertigo=central positional nystagmus=malignant positional vertigo 
386.3 Labyrinthitis 
386.30 Unspecified Labyrinthitis 
386.31 S Serous Labyrinthitis=diffuse Labyrinthitis 
386.32 Circumscript Labyrinthitis=focal Labyrinthitis 
386.33 Purulent labyrinthitis 
386.34 Toxic Labyrinthitis 
386.35 Viral labyrinthitis 
 
386.4 Labyrinthitic fistula 
386.40 Unspecified labyrinthitic fistula 
386.41 Round window fistula 
386.42 Oval window fistula 
386.43 Semicircular canal fistula 
386.48 Labyrinthitic fistula in combined sites 
 
386.5 Labyrinthitic dysfunction 
386.50 Unspecified labyrinthitic dysfunction 
386.51 Unilateral hyperactive labyrinth 
386.52 Bilateral hyperactive labyrinth 
386.53 Unilateral hypoactive labyrinth 
386.54 Bilateral hypoactive labyrinth 
386.55 Loss of unilateral labyrinth reactivity 
386.56 Loss of bilateral labyrinth reactivity 
386.58 Other forms and combinations 
 
386.8 Other labyrinth disorders 
386.9 Syndrome of vertigo and unspecified labyrinthitic disorders 
 
780 Symptoms, signs and badly defined states 
780.4 Vertigo and dizziness 
 
078 Infectious and parasitic diseasesa 
078.8 Other diseases specified by virus and Chlamydia 
078.81 epidemic vertigo 
a

Not used in the study.

To calculate the significance of the vertigo symptom in hospital outpatient departments we calculated total consultation proposals which had been made for any reason at the hospital, from PC to emergency services, during 2012. Among them, those carried out by the Otorhinolaryngology (ENT) and neurology services stood out as the main units to receive patients affected by this symptom.

The management model of the department in which the study was carried out is based on the health concession model. This management model, known as the Alzira Model, is sustained by 4 essential pillars: public property, public control, public financing and private control. It includes comprehensive healthcare, combining PC and specialised care. The department has a global electronic and integrated clinical record with PC, called Florence. Each external consultation proposal made in Florence is associated with the final service as an “episode” of outpatient surgery. This episode generates successive visits and additional studies up until its close, when the patient is discharged.

At the time of this study the department attended a per capital population of 153526. The main demographic characteristics were: increase in the population on a seasonal basis, with figures rising to 600000 inhabitants, an elderly population (26% over 65) and a large immigrant population (55% are foreign).

For each external consultation proposal the following variables were analysed: original and final service, ICD code used, year and month of referral.

Demographic and clinical patient variables from the review of the clinical history of each proposal were analysed, as were the administrative variables of the episode:

  • -

    Age, gender and country of birth.

  • -

    Associated psychiatric or psychological disorder.

  • -

    Emergency consultation for vertigo, both in the hospital emergency service and the health centre.

  • -

    Services which assess the patient.

  • -

    Number of vertigo episodes per patient in any speciality.

  • -

    Circumstances of the episode associated with the consultation proposal: open and active, open without activity (the patient stopped going) or closure due to medical discharge.

  • -

    Time the episode remained open (in months).

The information obtained from the Florence electronic modules and Florence clinical modules of the electronic clinical history were analysed using the IBM® SPSS® 20.0 statistical package for Windows 8. The qualitative information was presented in frequencies and percentages, and the quantitative information as means and standard deviation.

This study has the appropriate deontological certification from the Research Commission.

Results

Of the per capita population of 153526 attended in the health department when the study took place, 494 patients were assessed at their first visit to the hospital for symptoms of vertigo in the years 2011 and 2012. This led to annual rate of 1.6 initial visits of vertigo per 1000 inhabitants per year.

During 2012, 48778 referrals to the hospital were made from PC and 4042 from the emergency services. Vertigo made up 6% of all the proposals carried out from the PC to ENT. However, for neurology the referral by symptom represented 2.8%. Vertigo was the reason for .2% of the total referrals from PC to hospital (Table 2).

Table 2.

Context of Hospital Referrals in 2012.

  Total number of consultation proposals  Number of consultation proposals for vertigo  Percentage which represents vertigo 
From PC to hospital  48778  243  0.5 
From PC to ENT  3208  193 
From PC to neurology  1365  39  2.9 
From Emergency department to hospital  4042  19  0.5 
From Emergency department to ENT  223  13  7.2 
From Emergency department to neurology  155  1.3 

PC: Primary care; ENT: Ear Nose and throat.

The percentage reflects the weight of the vertigo and dizziness symptoms with regards to the total referrals made within the specified services.

A total of 558 proposals were analysed which corresponded to 494 patients, 275 carried out in 2011 and 283 in 2012. Distribution by gender and age is shown in Fig. 1. We noted that two thirds of the patients studied were women, with a mean age of 58 (range 3–91), and a third were foreign (Table 3).

Figure 1.

Distribution of the sample by age groups and gender (No.=494).

(0.05MB).
Table 3.

Demographic, Clinical and Administrative Characteristics of the Sample.

Gender, %   
Women  63.6 
Men  36.4 
Age in years, mean±SD  58.0±18.5 
Place of birth, %
Spain  65.4 
United Kingdom  12.6 
Europe (excluding above countries)  13.9 
South American  5.7 
Othersa  2.4 
Psychiatric or psychological medical historya  17.6 
Presented at the emergency department for vertigo  41.3 
Services which assess the patient, %b
ENT  88.3 
Neurology  24.0 
Physiotherapy  7.0 
Internal medicine  1.2 
Cardiology  1.2 
Orthopaedics  0.8 
Number of episodes per patient, %
One episode  41.5 
Two episodes  27.7 
Three episodes  13.4 
Four episodes  6.1 
Five or more episodes  11.3 
ICD code used for referral, %
Unspecified vertigo and dizziness  70.0 
Peripheral NEOM vertigo  9.7 
Benign paroxysmal positional vertigo  8.7 
Ménière's syndrome  6.1 
Vestibular neuritis  2.0 
Othersc  3.5 
Resolution of episode, %
Discharge  80.6 
In follow-up  5.9 
Withdrew from follow-up  13.6 
Time until discharge in months, mean±SD  3.4±5.4 

ICD: International classification of diseases; SD: standard deviation.

a

China and Australia.

b

Percentages not exclusive

c

Other peripheral not otherwise classified vertigos, laberynthitis, labyrinthitic fistula of combined sites and syndrome of vertigo and not otherwise specified labyrinthitic changes.

Of the patients studied, 17.6% had a clinical history of psychiatry and/or psychology in the hospital: 7.3% related to depression, 3.8% anxiety, 3.4% anxiety-depression and 3% to other psychiatric diagnoses.

Regarding emergency department attendance, 41.3% of patients presented at this service with vertigo, either to the hospital (29.6%) or health centres (27.7%).

With regard to the origin of the patients, 77.5% of them were referred from PC, 8.3% from emergency services and the rest from other hospital specialities: 4.7% ENT, 2.4% neurology, 1.6% internal medicine.

With regard to the patient assessment services, 76.1% were referred from a single service, 21.1% from 2 services and 2.8% from 3 services. ENT assessed 88.3% of patients and neurology 24.0%. The breakdown of services involved is reflected in Table 3. 41.5% of the sample had a single episode of vertigo in the hospital, 27.7% had 2 and 30.8% has 3 or more episodes. The maximum number of episodes open due to vertigo in one patient was 21.

The month in which further referrals were made was July (10.9%), followed by January and February (9.9%). The months with the least referrals were Septembers (5.5%), August (5.9%) and December (6.7%).

The most used ICD-9 code for referral was 780.4, which corresponded to vertigo and dizziness, at 70%. Three quarters of the patients were given a discharge within the first 4 months.

Discussion

This study showed, for the first time, how the symptom of vertigo affect the hospital setting, the burden it entails and what the flows of patients who present with it are like. Having a universal healthcare system, we worked on a population base which enabled us to reach conclusions regarding the true epidemiology of the studied symptom.

According to our study, the annual rate of vertigo in hospital is 0.16%. If we extrapolate the data from a study conducted in Spain,8 which estimates that 1.8% of the population consulted in PC for vertigo in a year, we could say that proximately 10% of patients who presented at PC with vertigo are referred to a hospital. Another study conducted in Germany12 concluded that only 3.9% of patients with the symptom had been referred to hospital. This difference could be due to the very different healthcare models. In Spain, there is a National Health Service model, whilst in Germany the Social Insurance System prevails, access to a specialist is free, but is only reimbursed if referral is made by a first level physician.12

In our study, referral for vertigo accounted for 0.5% of all referrals from PC to hospital. Of these, 79% were to ENT and 16% to neurology. ENT receives 6% of the total proposals made from PC, a result which is in keeping with previous reports.13 The symptom vertigo represents 6% of all ENT referrals, a percentage which also coincides with that reported in other studies.14 This allows us to extract conclusions from our series in more reliable and reproducible ways in our environment.

The predominance of women and a mean age of 58 are similar to other studies.3,4,6,8,19 On studying the country of origin of the individuals in our series., the proportion may be superimposed on the population studied: There are no differences by country of origin or language.

As has already been reflected in other studies, there appears to be an association between vertigo and psychological co morbidity, mainly depressive symptoms,1 and the psychiatric condition may be even predictive of reactive symptoms in vestibular patients.20 In our study, one out of every 5 patients presented with a history of psychiatric or psychological disorders. 11% suffered from symptoms of depression and 7%, from anxiety. However, the literature shows there is a higher prevalence of depressive symptom in patients with vertigo (up to 20%).21 We should also bear in mind that our study only accounts for patients seen by menial health specialists, and not those diagnosed and treated by PC.

It is known that vertigo and dizziness are very common reasons for emergency service consultation. In North American studies15,16 it has been reported that it accounts for between 2% and 3% of all emergency department consultations. The individual probability of presenting at the emergency department for vertigo has not been described, but in our series, almost half of the patients had at some time presented because of this symptom.

PC takes care of over 75% of referrals from vertigo, and the emergency department around 10%. From PC and the emergency department, in one year, 206 referrals were made to ENT for vertigo and only 41 to the neurology department. This is a striking difference and its origin could be based on several factors. Firstly, we could suggest that there was greater accessibility to the ENT service, both in number of consultations during the morning and afternoon and due to local shift hours. The mean delay time for an initial visit could also be relevant, as this is lower for ENT in our setting. Another aspect to consider would be appropriate communication of the PC practitioner with the ENT service, using several channels which have been established in the hospital, such as non presential interconsultation or the figure of the ENT specialist concerned, for each healthcare centre. Fluid two-way communication encourages trust when there are referrals. The last explanation is that this difference could also be due to the inadequate training from PC, with a false belief that the symptoms of vertigo and dizziness always have an ENT diagnosis. Our department works jointly with PC in referral protocols and in training sessions on vertigo.

In this study, almost 90% of patients were assessed by the ENT service. This data is striking since the majority of epidemiological studies on the symptom of vertigo are conducted by neurologists.1,2,4,9–11,20 Neurology assesses a quarter of the patients and physiotherapy less than a tenth. This study provides an overall view at what is happening with patients vertigo in hospital, without this being limited to individual selection by specialities.

76% of patients were assessed by a single service, 21% by 2 and just 3% by 3 or more. This contrasts with the number of episodes due to the same symptom: 41% had a single episode, 28% 2 episodes and 31% 3 or more episodes, with a mean of 2.4 episodes per patient. Repetitive consultations due to the same symptom is of note here.

82% of patients were discharged from the surgery, the majority during the first 4 months. Fewer than 5% of the episodes remained open and 14% of patients had abandoned follow-up. Two very different interpretations could be made from these data, for a fast resolving disease by the specialist. The first of these is that it is not a complex disorder and requires few additional tests, and medical discharge may therefore be given early. The second, and in our opinion the most correct, is that the service treating it considers that vertigo and/or dizziness are not caused by the illnesses of their speciality. The patient is therefore discharged without resolving the problem of vertigo and this leads to repetitive consultations. This is where we put forward the benefit the otoneurology units provide with global, interdisciplinary and comprehensive patient care.

No differences were observed between the months of referral, and there were no seasonal differences in the demand for consultation due to vertigo.

70% of the proposals were coded within the group of non specific symptoms, 780.4, similarly to another study.11 It is logical to think that referral means there is no clear diagnosis, and “vertigo and dizziness” are therefore appropriate as a title for the proposal consulted. In itself we cannot define it as a diagnosis. The other statements corresponding to code 386 include highly precise diagnoses which may only be given after specialised testing has been conducted.9 Of these, the most reported was benign paroxysmal positional vertigo, one of the most frequent diagnoses and one of the easiest to detect within otoneurological diseases.1–3,6,17,18

The study has limitations due to being retrospective. With regards to the total number of referrals from PC and the other specialties, we are not working with a total of individuals, but with proposals. Were it so, this would be a better reflection of the population referred to hospital within the department.

This study analyses referrals for a symptom, without bearing in neither mind a final diagnosis nor patient evolution. It therefore does not describe a prevalence but a series of new cases which require attention during a certain period of time.

In view of how complicated it is to study the epidemiology of a symptom, and in this particular case of vertigo and dizziness,1,2,4,8 our aim is to provide new information on a underdeveloped area which may help to improve the quality of care of the patient with vertigo. A consolidated sub-speciality exists in our area, which is otoneurology. According to a survey conducted in Spain,22 otoneurology has been established in half of the health centres and those without it consider it to be necessary.

The aim of this study is also to establish the bases for future research studies on the clinical management of each patient, the resources used by the health system for resolving their problem and the outcome of the different cases.

Conclusions

The symptom of vertigo is a significant burden in the hospital environment. Patients who experience it present on many occasions and are assessed by different specialities. This implies that in some cases the flow of patients is overly dynamic and ineffective.

In our setting, ENT is the main department which receives patients with symptoms of vertigo and dizziness.

It would be beneficial, both for the patient and the healthcare system, to establish recommendations as a guide to be followed when a patient presents with vertigo.

A final reflection is that we consider it useful for otoneurology units to be established in the hospital setting, so that interprofessional communication and interlevel care may be present, in addition to continuous professional training.

Conflict of Interests

The authors have no conflict of interests to declare.

Acknowledgements

Our thanks to the physicians of the ENT services in the University hospital of Torrevieja, for their critical review and for sharing their experience. Also to Dr. María Carmen Botella García, a specialist in family and community medicine from the healthcare centre of Patricio Pérez (Torrevieja), for her much appreciated collaboration. Thanks also go to the research service of the University hospital of Torrevieja for their critical review of the project and for their scientific advice.

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Please cite this article as: Bécares Martínez C, Arroyo Domingo MM, López Llames A, Marco Algarra J, Morales Suárez-Varela MM. Vértigo y mareo en el hospital: frecuentación, flujo y características de los pacientes. Acta Otorrinolaringol Esp. 2018;69:219–225.

Copyright © 2017. Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello
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