Dizzy patients are among the most challenging, time-consuming cases that are seen in otolaryngologists’ offices. The cause of the vertigo is often difficult to establish, and effective treatment is often elusive. Therefore, it can be helpful to know which vestibular tests can be effectively conducted in the general otolaryngology clinic and which ones are typically performed in a referral clinic specializing in balance disorders.
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April 2006In several phone interviews, several vestibular disorder experts discussed some basic in-office techniques as well as novel testing modalities that are typically available in referral clinics or hospitals.
Patients who present with vestibular complaints typically will involve more time than the usual patient with sinusitis or middle ear fluid or any number of other pathologies that the general otolaryngologist encounters, said James Soileau, MD, the senior partner of the Ear and Balance Institute in Baton Rouge, La.
Often it’s difficult to get a clear history because the dizziness has been ongoing for some time. Therefore, the most important consideration is to be able to allocate some extra bit of time to get a very good history. The clinical exam should include extra diagnostic tests to get a good clinical picture on the first visit.
Those tests should be accompanied with good counseling from the physician regarding the tests’ potential benefits, said John Epley, MD, Director of the Portland Otologic Clinic (Ore). The major problem with most vestibular testing is patients’ over-expectations regarding what benefits they will get from the test, said Dr. Epley. They are not aware of the limitations of the tests commonly performed in clinics.
We need to heighten the awareness of migraine and superior canal dehiscence to stop these cases from falling through the cracks, – Dr. Goebel said.
Other problems include out-of-date standards and reimbursement difficulties, he said. All of these barriers can result in inadequate testing of vestibular patients.
A Poorly Understood Urgency
Vestibular testing is currently poorly covered, with reimbursement often not available or sharply discounted. The reason for this is that the urgency of dizziness is poorly understood, Dr. Epley said. People can die from falling, but dizziness is not seen as something that can kill you, he said. It’s taken a long time for people to understand that dizziness originates in the ear in 95% of cases.
The otologic origin of dizziness is still poorly recognized, he said, noting, I frequently see patients who have been sent to psychiatrists for vertigo. Dizziness increases in prevalence with age, he said. Approximately 9% or 10% of elderly have BPPV [benign paroxysmal positional vertigo], but they’re dizzy and don’t know why, he said. The lifetime chance of developing vertigo must be 25% to 50%.