Mohamed A. Hamid, MD, PhD, believes, as a matter of principle, that an office vestibular examination is necessary before ordering electronystagmography (ENG)-or any other vestibular diagnostic tests, for that matter.
Considered one of the foremost experts on treating balance and dizziness, Dr. Hamid, along wtih his team at the Cleveland Hearing & Balance Center, spent more than a year studying the predictive value of office vestibular examination in forecasting ENG test results. At the recent American Academy of Otolaryngology-Head and Neck Surgery Annual Meeting in Toronto, he reported that the findings are encouraging.
The study, Prediction of ENG Results from Office Vestibular Examination, concluded that vestibular exams are highly sensitive in predicting ENG test results in 95% of vestibular patients, and went on to state that physicians can rely with confidence on office vestibular examination when ENG is not available.
This presentation created either very positive or very negative feelings in the audience at the Toronto meeting, Dr. Hamid said. Some felt very negative perhaps because of lack of ability to do office vestibular exams, lack of time, or because of financial implications.
Dr. Hamid said other physicians thought it was promising because many otolaryngologists, especially those in remote areas, do not have ready access to tools such as ENG.
But I also believe the message was misconstrued quite a bit, he said. The vestibular industry was not happy about the presentation either.
At this juncture of my career, my responsibility is primarily to my patients, expanding the knowledge of auditory and vestibular medicine, and providing cost-effective management of hearing and vestibular disorders. We are currently studying the same concept for other expensive diagnostic tests such as MRIs.
Gerard J. Gianoli, MD, of Baton Rouge, La., said he had several questions regarding the study’s conclusions, but pointed out that Dr. Hamid’s full study has not yet been published, so it is too early to accept or dismiss the findings from an abbreviated abstract presentation.
I cannot say, based on the results we have been provided, that the conclusions here can be supported, Dr. Gianoli said. But I’d like to see the full study before making any concrete determinations.
The prospective study was completed over the course of one year in a tertiary-care hearing and balance center. The sample population was made up of 100 patients, each presenting with dizziness or vertigo, who underwent an office vestibular examination using Frenzel’s glasses or video monitoring and ENG tests.
The examination included spontaneous, positional, and vestibular-induced eye movements, while a laboratory-based ENG used surface electrodes and standard protocol to acquire and analyze oculomotor and vestibular eye movements.
The audiologist was blinded to the physician’s a priori prediction of ENG results.
Vestibular exam and ENG results were correlated to determine the percentage of correctly predicted results.
The study showed 100% predictive sensitivity of vestibular exam for spontaneous, post-head shake, and nonparoxysmal positional nystagmus. The vestibular exam sensitivity for predicting unilateral vestibular hypofunction was reported at 95% compared with caloric results.
Dr. Hamid concluded that the study determined that office vestibular examination is highly sensitive in predicting ENG test results in 95% of vestibular patients. He further concluded that physicians can rely with confidence on office vestibular examination when ENG is not available.
Dr. Hamid said the takeaway message from this study is not that ENG is no longer a viable method for screening dizzy patients-far from it. Instead, the intention was that ENG, like other tests, is a tool to be used in conjunction with the knowledge and expertise of each individual physician.
Nothing in this prospective study suggests we cannot or should not use ENG on our patients, Dr. Hamid said. A vestibular exam is not a replacement for the ENG, but the ENG should be used to complement the examination findings.
A physician properly versed in how the vestibular system works, and who does not have access to an ENG, should use a vestibular exam as an outline to glean enough information to indicate if an ENG is needed, Dr. Hamid said.
Doctors in rural areas many times do not get access to tools like an ENG, but they still need to get an idea of what is going on with the patient, Dr. Hamid said. In fact, vestibular examination can be video recorded for objective documentation of findings. It has to be emphasized that the knowledge and training of the examining physician regarding the vestibular system is very critical.
Dr. Hamid added that it is encouraging to see that several otolaryngology programs are now including advanced vestibular training in their curricula.
However, Dr. Gianoli said he is concerned with how the vestibular system expertise of the average otolaryngologist stacks up against a leading-edge dizziness expert of Dr. Hamid’s caliber.
You just can’t say that a neurotologist who does nothing but ‘dizzy work’ will have the same results as a general ENT, Dr. Gianoli said. It is one thing for someone with as much experience treating dizzy patients as Dr. Hamid to be able to glean the proper diagnosis from an office exam, but to expect a general ENT to replicate those results is a significant leap.
Regardless of whether ENG is readily available, otolaryngologists should perform an office vestibular exam on their dizzy patients as a matter of principle, Dr. Hamid said. The general trend shows physicians spending less and less time with patients, and instead ordering many diagnostic tests before actually seeing the patient. Dr. Hamid called this trend less than optimal for quality care.
We all examine the ear and use the tuning fork test to get an idea of hearing before going on to get an audiogram, he said. Even if you have an ENG, a physician would be better off examining the patient before getting an ENG to confirm his or her own data because it makes a better physician. I’m not talking about replacing ENG with an office exam.
Another important issue is that many nonphysicians are now claiming expertise in dizziness, using vestibular test equipment with minimal training.
The vestibular industry is supporting this trend, Dr. Hamid said. It is expanding and will eventually undermine the clinical utility of vestibular testing and force third-party payers to look very hard at all users-including otolaryngologists and otologists. I am hoping that we can be proactive in slowing this trend.
It is a cold fact that hands-on examinations of patients cannot be recorded in the same quantifiable way that an ENG can, making it much harder for physicians to get paid for the work they are putting in. No two physicians will record exactly the same data from an office exam, making it hard to establish a coding system.
If you don’t have a recording of it, you’re not going to get paid, Dr. Gianoli said. So basically you’re talking more work for less money. You can also base future studies off ENG data, which is not true of the subjective data gleaned form an office examination.
Dr. Hamid agreed that the financial issues made adoption of his suggestions more difficult.
Let us be blunt-physicians are not appropriately rewarded for their cognitive abilities and we have been forced to use technology to circumvent that trend, he said. I still think it is always important to see the patient first, make a determination what is needed and then order further diagnostic tests-that is what medicine is all about.
I think we as physicians are in a dilemma here because, from a business point-of-view, it is difficult for most of us. If you need to see 20 or 30 patients a day, then you won’t have the time to do a full vestibular exam. But not everyone sees 20 to 30 a day.
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