Vestibular Diagnostics For All of Us



Author: Mark Caffrey, Au.D.

I was chatting recently with a patient during a VNG evaluation. I was informed, by this surprisingly technology savvy eighty-plus year old woman, that in her web search for “dizziness specialists,” audiologists did not get even an honorable mention! She was actually shocked, she continued, when her physician referred her to me, her “hearing aid doctor,” for testing and possible diagnosis of her dizziness complaints. This particular patient has been a hearing aid patient of mine for more than eight years. I admit that I too was both shocked and even a little hurt by her disclosure.

Later, I retired to my laptop and began my own internet search... like a patient. I avoided the professional websites that we so easily utilize as audiologists and instead began my search like a patient would; I turned to Google, Yahoo and Bing. My search topics included: Dizziness, Dizziness Specialists, Who Tests for Dizziness, Who Treats Dizziness, and the same searches using “BPPV” instead of the word “Dizziness”. Each of these searches resulted in essentially the same results.

Unfortunately, my search results were no different than my patient's findings. With just a single exception, audiologists are not mentioned at all. Since, by definition, audiologists are “trained to diagnose, manage and/or treat hearing or balance problems” (Wikipedia, 2014) this was disheartening to say the least. Most search results (YahooAnswers.com, Healthboards.com, MedLine.com, WebMD.com, UIHealthcare.org, Medicine.net, MedScape.com, and HealthCommunities.com) did not mention the audiologist in any capacity. The suggested sources for the diagnosis of dizziness were overwhelmingly in favor of the primary care physician, which we could concede is a logical place for patients to start—but then the search results directed prospective patients to the neurologist next, then the ear, nose & throat physician, and lastly to physical therapists; even neurotologists managed to obtain only one mention. One of the sites, MedLinePlus.com, the website of the National Institute of Health/National Library of Medicine, stated that the primary physician might order hearing testing and ENG testing but failed to mention what specialist would provide those specific services (MedlinePlus, 2013). Regarding the treatment of dizziness and/or Benign paroxysmal positional vertigo (BPPV), all the various sources listed the primary care physician, the ENT, the physical therapist, and even the occupational therapist. Again, the audiologist was omitted.

One solitary site during my search specifically listed audiologists as a source for the diagnosis and/or treatment of dizziness. This site is ShareCare.com. In fact, at this source, ShareCare.com, the Honor Society of Nursing lists the audiologist as the preferred source, followed by ENTs and neurologists only if the dizziness is linked to brain anomalies (Honor Society of Nursing, 2013). These mostly unflattering search results reminded me of a New York State Speech Language Hearing Association (NYSSLHA) conference a couple of years ago when one of the presenters asked the audience how many audiologists in attendance were treating BPPV in the office. Sadly, I was the only one to raise my hand. All this brings me to the ultimate purpose of this article. The American Academy of Audiology (ADA), in its bylaws, has challenged audiologists to advance “the science and practice of audiology, and [achieve] public recognition of audiologists as experts in hearing and balance” (AAA, 2014). Audiologists need to do a more effective job representing themselves as more than hearing experts; we need to step up to the plate and fulfill our mission completely. We have clearly not achieved public recognition as experts in balance disorders.

Many audiologists simply may not wish to get involved with VNG assessment or may not have the funds necessary to invest $35,000-75,000 in a vestibular diagnostics lab, let alone have the physical space required to provide complete vestibular/balance rehabilitation services. However, for a very modest investment of about $300, any audiologist could begin to provide diagnosis and remediation for the most common form of dizziness. BPPV accounts for half of all the dizziness complaints of our elderly patients (Hain, 2014). A simple Dix-Hallpike maneuver, performed on a very basic flat therapy table, costing about $300, will allow you to determine if BPPV is present. The positive Dix-Hallpike will yield a torsional (rotary) nystagmus that has latency, short duration (paroxysmal), and fatigues; this will be accompanied by vertigo and sometimes nausea. This torsional nystagmus will beat toward the affected ear (Hain, 2014). While use of Frenzel lenses or VNG recording assures that even the most subtle variations of BPPV are identified, nearly all BPPV can be visualized with the naked eye.

Once identified, the same inexpensive therapy table can then be used to perform any of the canalith repositioning procedures to treat BPPV. The Epley maneuver is the most widely used method in the United States, but I personally prefer the Semont maneuver, which is more commonly utilized in Europe. The Epley maneuver is gentler on the back and is easier to perform on larger patients and patients unable to move rapidly, but it does require a head-hanging position which can be difficult for some elderly patients with limited neck mobility (Hain, 2014). It also requires a bit more time. The Semont maneuver entails moving the patient very rapidly, which can be difficult with arthritic or frail patients or patients with bad backs, but does not require a head-hanging position. The Semont maneuver requires less time and it has a success rate of approximately 90% (Hain, 2014). Reimbursement for audiologists is often problematic with all canalith repositioning, but having the patient sign an ABN (advanced beneficiary notice) resolves this.

With such a meager investment, audiologists in nearly all practice settings could begin to diagnose and treat at least the most common cause of dizziness for our patients. If the Dix-Hallpike test is negative, a referral to a colleague that offers VNG and possibly vestibular rehabilitation services would be appropriate. We need to utilize each other and should not fear losing this patient to a competitor. Very few of us consistently provide comprehensive central auditory processing evaluations but may perform a screening and/or provide a referral to a colleague; even fewer of us are directly involved with cochlear implants, but we certainly have the capacity to refer potential candidates to the appropriate facility for further evaluation and treatment. We should therefore exercise the same ethical duty to our patient's well-being by referring them to other colleagues when necessary for more advanced diagnosis and treatment of vestibular disorders. Our wonderful profession is not only about hearing aid sales. If we do not represent ourselves as THE specialists for the diagnosis and remediation of vestibular and balance disorders, why would the primary care physician, who will most likely make such a referral, do so? The provision of this very minimal diagnostic procedure and subsequent remediation will not only provide very significant benefit to our vertiginous patients, but will also help our profession better meet its mission to establish ourselves as the experts in hearing AND balance disorders.    
Mark Caffrey, Au.D., Caffrey & Associates Audiology, can be contacted at caffreyaud@hotmail.com.

This article originally appeared in the New York State Speech-Language-Hearing Association’s Communicator, 44, 2, 18-19.

References
"Bylaws", American Academy of Audiology, retrieved on January 15, 2014

"Dizziness", MedLinePlus.com , retreived December 21, 2013

Hain, Timothy C., MD, "Benign Paroxysmal Postional Vertigo", Dizziness-and-Balance.com, January 8, 2014, retreived January 15, 2014

"What Type of Specialist Treats Vertigo & Dizziness?", The Honor Society of Nursing, retreived December 21, 2013

Wikipedia: definition of Audiologist, retrieived January 15, 2014