vestibular disorders

Vestibular Testing Safety: COVID-19 and Beyond

All recommendations are made with the best current information and in the context of a multifaceted safety program. When a variety of safety measures are put in place our chance of protecting our patients and colleagues increases.

All safety recommendations assume that

COVID-19: Considerations for Treatments Using Quinine Derivatives and Other Ototoxic Compounds

Hydroxychloroquine was recently approved by the U.S. Food and Drug Administration (FDA) for emergency use to treat adults and adolescents with COVID-19.

Vestibular Evaluation and Rehabilitation: A Team Approach for Audiologists and Physical Therapists

Dizziness and imbalance are complex and, often, multifactorial conditions that require skilled evaluation, sometimes by multiple health-care providers.

As audiologists, our role is largely diagnostic in nature. We are able to perform a variety of tests to help identify or rule out the site of lesion. Working in a collaborative team with physical therapists who are specifically trained in vestibular rehabilitation provides a comprehensive and dynamic approach to treating these patients.

Topic(s): vestibular evaluation, vestibular disorders, therapy

Author(s):

Brad Stewart

Kristen Crawford

Publication Issue: Audiology Today May/June 2020

Alternatives to (Not Substitutes for) Caloric Testing

The standard electronystagmography/videonystagmography (ENG/VNG) exam, first described 80 years ago, has been around for about 60 years. The recording techniques have improved, but the tests are the same. Our understanding of vestibular function and methods to evaluate the vestibular ocular reflex (VOR) also have improved, but our profession still relies primarily on VNG testing to determine vestibular function. Let’s take a critical look at this standard of care.

Topic(s): vestibular disorders, vestibular evaluation, Vertigo, vng, videonystagmography

Author(s):

Alan L. Desmond

Brady S. Workman

Publication Issue: Audiology Today March/April 2020

Eerie Experiences of the Ear (Inner)

Have you ever had an “out-of-body” experience (OBE)? An OBE is considered a state where your center of awareness is located outside of your physical body, along with the sensation of seeing the environment from an elevated position. Current neuroscientific models of OBE suggest failure in integration of visual, somatosensory, and yes, vestibular input.

Clinical Vestibular Audiology Training of AuD Students: One Clinic’s Perspective

During doctor of audiology graduate programs, students are expected to complete coursework and clinical training experiences across the breadth of the profession. Depending on the curriculum of the school and the clinical experiences available, the quality of their clinical training may vary, particularly in some of the specialty areas within audiology.

Topic(s): vestibular disorders, clinical education, clinical audiology

Author(s):

Daniel S. Talian

Publication Issue: Audiology Today November/December 2019

Academy Supports Balance Awareness Week

The Academy is proud to help support Balance Awareness Week—September 15–21, 2019. Balance Awareness Week, an observance designated by the Vestibular Disorders Association (VeDA), aims to increase awareness about vestibular disorders and support patients in their journey back to balance.

While many balance disorders are incurable, faster and more accurate diagnosis, along with effective coping strategies can greatly improve quality of life.

Ask the Expert: Concussion

Physical Therapist: Shelly Massingale, PT, MPT

1. Concussion has received significant media attention over the last few years. What is a concussion?

The CDC defines concussion as “a type of traumatic brain injury or TBI- caused by a bump, blow or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth.” Concussion is commonly referred to as a mild traumatic brain injury (mTBI) and is typically associated with normal structural imaging (normal CT/MRI). Symptoms of concussion can include dizziness, headache, cognitive changes, mood changes, balance problems, and nausea and vary from person to person and from injury to injury. Concussion is considered a transient injury that typically lasts a few days to a several weeks before full recovery.

2. Dizziness and balance problems are common after concussion. Why are these symptoms so common?

Dizziness and balance problems that occur after a head injury are often the result of damage to either the peripheral or central vestibular system. Our vestibular system is comprised of our inner ear (peripheral vestibular system), the vestibular nerve (connects the peripheral to the central vestibular system), and the areas in the brain that process that information (central vestibular system). If any of these areas have been affected, the injured person could experience feelings of dizziness, being off balance, vertigo or a combination of these. Our vestibular system is highly sensitive to movement, so any damage or disturbance to these areas cause symptoms while performing activities of daily living.

3. Do you recommend that patients pursue vestibular rehabilitation after a concussion?

If a patient sustains a concussion and has any symptoms of dizziness, vertigo, imbalance, or nausea that last more than a few days, I highly recommend pursuing vestibular therapy. Vestibular therapy an effective treatment, and having a specialist take you through a course of treatment will allow you to recover more quickly. The patient’s physician typically makes the initial referral to vestibular therapy after a thorough medical evaluation of concussion.

4. If so, what vestibular rehabilitation techniques help to reduce symptoms and improve function?

The technique used in vestibular therapy depends on the nature and severity of the symptoms, as well as the underlying cause. When someone sustains a concussion, symptoms of vertigo may occur with positional changes. This diagnosis is called Benign Paroxysmal Positional Vertigo (BPPV), which commonly occurs after head injury. The treatment for BPPV is very specific and should be performed by a trained clinician. If BPPV is not present, then balance exercises and vision retraining exercises that address how the head and eyes move together are very effective in reducing dizziness and imbalance. Exercises selected are highly specialized and very specific to the individual’s symptoms and daily activity demands, and should only be performed by a clinician that has training in this type of therapy.

5. Are there specific exercises or strategies most helpful for improving symptoms after concussion?

See above answer 4.

6. Do you recommend vestibular rehabilitation for all patients post-concussion? Are there patients with certain symptoms who benefit most?

Vestibular therapy is not indicated for every patient who sustains a concussion. Some people will be diagnosed with a concussion and will not have any symptoms related to dizziness, imbalance or vertigo. These patients do not need to participate in vestibular therapy. On the other hand, any person who is experiencing dizziness, vertigo, and/or imbalance after sustaining a concussion would likely benefit from participating in vestibular therapy, especially if the symptoms persist for more than a few days.

7. I’ve had quite a bit of neck pain and stiffness after a car accident. Could this be the cause of my dizziness?

Cervicogenic dizziness can occur with a whiplash injury and is often diagnosed with concussion. Cervicogenic dizziness is defined as the presence of dizziness, imbalance or unsteadiness related to movements or position of the cervical spine or related to a stiff or painful neck. The treatment for cervicogenic dizziness is therapy for the neck to help decrease the discomfort and stiffness. Reducing stiffness and muscle imbalance in the neck can help to decrease the sensation of dizziness.

8. Are there any screening measures or tests available that you’d find helpful to have prior to seeing a patient referred for VRT?

Prior to starting VRT, a patient should be evaluated by a physician with specialized knowledge about concussion and brain injury. A concussion can cause a myriad of symptoms in addition to dizziness/imbalance, so a thorough and complete assessment of post-concussion symptoms is necessary to determine the correct course of treatment for each individual. Depending on the severity of the injury and the symptoms, an audiology evaluation may be helpful to more thoroughly assess inner ear function. The physician overseeing the case usually determines which clinical tests need to be performed prior to initiating vestibular therapy.

9. What would you want the general public to know about concussion rehabilitation?

Concussion rehabilitation is most effective and efficient when the patient receives a multidisciplinary evaluation and individualized approach to care. Concussion is a complex injury which should not be addressed using a “cookie cutter” approach to treatment and focusing on treatment of only one aspect of concussion may lead to a longer recovery.

10. What is your overall key take home message for providers working with patients with suspected post-concussion dizziness?

I would highly recommend that the provider working with post-concussion dizziness complete specialized training that addresses the nature of concussion/brain injury and reviews appropriate treatment protocols. I cannot stress enough the importance of having a multidisciplinary team of clinicians overseeing the treatment, management and rehabilitation of patients to ensure the patient is receiving the best care for his or her injury.

Shelly Massingale is the senior director of Banner Concussion Services in Arizona and Colorado. She is a physical therapist and has been a specialist in vestibular and balance therapy for the past 22 years. Shelly has focused her treatment and research primarily in mild traumatic brain injury since 2013 and has lectured nationally and internationally on evaluation and treatment of vestibular and balance deficits related to mild traumatic brain injury.

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Ask the Expert: Vestibular Migraine

Vestibular Migraine: Kristen Steenerson, MD

1. What are the diagnostic criteria for vestibular migraine?

The criteria for vestibular migraine were developed jointly by the Barany Society and the International Headache Society in 2012. As vestibular migraine was still a newly accepted diagnosis at that time, strict diagnostic criteria were developed to establish universal research standards. As a result, many patients who have vestibular migraine may not fit into the classic criteria established over seven years ago. As the current criteria stand, patients are required to have at least five moderate to severe attacks of vertigo (defined as any hallucination of movement, not just spinning) lasting 5 minutes up to 72 hours at a time. With these attacks, migrainous features such as headache, photophobia, phonophobia or visual aura must be present half of the time. Finally, a previous or current history of more classically understood migraine helps to clinch the diagnosis.

2. What are common clinical signs and symptoms for patients with suspected vestibular migraine?

Patients with vestibular migraine typically have attacks of spinning, tilting, rocking, sway and imbalance. These are usually spontaneous, but can be linked to stress, poor sleep, dehydration, skipping exercise and meals. In between attacks, it is very typical for patients to have hypersensitivity to motion, sound, light, smells and medications. When evaluated by physicians, many of these patients are considered normal. However, with a keen eye, physicians will notice vestibular migraine patients have increased head motion sensitivity, visual motion sensitivity, and postural imbalance with exaggerated sway on occasion compared to patients without VM.

3. Are there specific vestibular tests that you find helpful for diagnosing vestibular migraine?

Unfortunately, there are still no gold standard diagnostic tests for vestibular migraine. Some interesting studies have been published highlighting some patterns in vestibular testing that may be helpful, but these are still in nascent stages and of uncertain generalizability. I find it still very useful to order the full battery of audiovestibular tests to make sure other vestibular disorders have been considered, especially Meniere's Disease, due to the considerable overlap in symptoms.

4. What management strategies are most helpful?

There are two main approaches to management: prevention and rescue.

Prevention focuses on reducing the total number of attacks and frequency of attacks that occur. A good prevention plan will reduce severity and frequency by 50%; it is rare that patients will see complete resolution of attacks. Prevention plans include lifestyle changes, medications and physical therapy. Lifestyle changes can be very effective in most patients and may be all that is needed. For lifestyle, we use the mnemonic SEEDS: Sleep, Exercise, Eating, Dehydration and Stress management. Regular sleep, exercise, drinking water (avoiding dehydrating drinks like caffeine/alcohol) and eating schedules can be helpful in reducing triggers for migraine attacks. Stress management is also a key lifestyle modification that comes in different forms for different people: meditation, mindfulness, talk therapy, exercise, work modifications and sometimes medications. Medications used for prevention are borrowed from the migraine headache literature. These can range from over the counter nutraceuticals such as magnesium and riboflavin to prescription medications such as antihypertensives, antidepressants, and anti-epileptic medications. Vestibular physical therapy can help desensitize the brain to head/body motion and visual motion to help reduce triggering of attacks.
Rescue focuses on reducing the duration and severity of an attack when it occurs. Medications typically used include anti-nausea, anti-inflammatory, anti-migraine, anti-histamine and anxiolytic properties that have dual purpose as vestibular suppressants. These medications must be used with caution as they are not intended to be used long term and can have longterm side effects. They are very safe if used a few times a month.

5. Are medications available for vestibular migraine?

In the United States, we commonly use already-established medications used in migraine headaches. These can range from over the counter nutraceuticals such as magnesium and riboflavin to prescription medications such as antihypertensives, antidepressants, and anti-epileptic medications. These are generally effective, but can sometimes require trialling a few different ones before a patient finds relief. There are no randomized controlled trials that support one medication over another in vestibular migraine in the United States. Europe and other countries have trials supporting the medications flunarizine and cinnarizine, but these are not available in the US.

6. Is vestibular migraine treated differently than other migraines?

Yes and no. In many ways the treatments are similar. Due to vestibular migraine's unique motion sensitivity and balance difficulties, there is a singular role for vestibular therapy that is not commonly seen in more typical migraine. As more studies are completed, there may be evidence of unique pathophysiologic processes for vestibular migraine compared to migraine headaches, which may implicate emphasis on different types of medications, but this is yet to be definitively established.

7. Do you recommend vestibular rehabilitation?

Yes. In the hands of an experienced vestibular therapist, I find that many vestibular migraineurs improve in terms of balance and motion sensitivities. There are severe cases where even the most gentle of ocular motor or balance exercises exceed the threshold of what a patient can tolerate. For those individuals, we will usually attempt lifestyle and medication interventions first before trying vestibular therapy.

8. What would you want the general public to know about vestibular migraine?

Vestibular migraine is incredibly common. Up to 3% of the general public has vestibular migraine.
It is important to recognize that headaches do not need to be a prominent feature in order to be diagnosed with vestibular migraine.
It is likely an inherited disorder that can become active with certain environmental factors such as stress, hormone fluctuations (e.g. menopause/perimenopause) and irregular sleep/eating/exercise/drinking schedules.

9. What is your overall key take home message for providers working with patients with suspected vestibular migraine?

Vestibular migraine, like other forms of migraine, is an episodic, neurologic, hypersensitivity disorder. Central nervous system and peripheral nervous system pathways are preferentially affected, resulting in vestibular attacks of variegating types of motion and motion sensitivity. As these pathways can sometimes activate independent from pain pathways, vestibular migraineurs can have isolated vestibular events without headache, thus absence of headache should not dissuade the diagnosis. Lifestyle changes are paramount, medications can be helpful, and physical therapy can be useful for treatment in many of afflicted patients.

10. Are there any other specialties you’ve found helpful to include in a vestibular migraine patient’s plan of care?

Due to known connections between the vestibular circuits and the emotional circuits of the central nervous system, most patients experience an increase in anxiety and/or depression related to their vestibular migraine. Attacks are unpredictable and frightening and if suboptimally controlled can trigger maladaptive coping such as panic attacks, hypervigilance and catastrophization. Due to the connection to mood changes, psychological support such as talk therapy and meditation can be beneficial for coping with this distressing disorder.

Kristen Steenerson is a board-certified neurologist with fellowship training in otoneurology. After graduating cum laude from Claremont McKenna College where she was honored as an All-American lacrosse defensive player, she continued on to medical school at the University of Utah in Salt Lake City, Utah. She then proceeded to Mayo Clinic in Arizona for neurology residency and a fellowship in otoneurology at Barrow Neurological Institute. Dr. Steenerson joined Stanford with positions in both Otolaryngology-Head and Neck Surgery and Neurology with the goal of jointly addressing the junction of inner ear and brain disorders.

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Ask the Expert: Vestibular Disorders

Vestibular Disorders: Habib Rizk, MD

1. Dizziness is a common symptom reported by many patients. As an otologist, what about patient-reported dizziness is most concerning to you? What disorders do you most commonly see in the clinic?

Any patient presenting with new neurologic symptoms associated with their dizziness requires a thorough evaluation to look out for central causes. These symptoms could be new onset headaches, slurred speech, paresthesia, weakness in lower or upper limbs. Also, patients with loss of consciousness need to be evaluated to rule out a hemodynamic cause or an arrhythmia. Finally, patients with dizziness associated with audiologic symptoms orients more toward a peripheral inner ear disorder.

In our multidisciplinary dizziness clinic, Meniere’s disease and vestibular migraine and BPPV account for about 50% of our new patients

2. Are there differences based on age? Do kids have the same trouble with dizziness as adults?

In children, migraine equivalents are the most frequent causes of dizziness, as well as post concussive dizziness. While vestibular migraine is prevalent in adults, benign paroxysmal positional vertigo is still the most frequent cause of vertigo in adults. Dizziness is a general term and can encompass vertigo, lightheadedness, imbalance.

3. Many patients have been diagnosed with Meniere’s disease. What is Meniere’s disease? What management is available Meniere’s disease?

Meniere’s disease is a pathology that affects the pressure control of the inner ear fluids resulting in fluctuating symptoms of ear pain, tinnitus and vertigo lasting between 20 minutes and 12 hours. There is a high association with migraines in a large subset of patients. Treatment ranges from low salt diet and diuretics to intratympanic steroids, intratympanic gentamicin injections and surgeries: to preserve hearing such as endolymphatic sac decompression or vestibular neurectomy or that are not hearing preserving such as labyrinthectomy.

4. If a patient experiences a sudden onset of spinning vertigo, should the patient immediately go to the emergency department or is there an alternative pathway to care that you would recommend?

A brief episode of vertigo (room moving or subject feeling that they are moving) lasting less than a minute and triggered by a change in head position, typically would not require a specialized evaluation and is usually a benign paroxysmal positional vertigo. However, as a precaution it is important to be evaluated to see if there is any reason to suspect a stroke. Rarely, posterior fossa strokes will manifest only as vertigo without associated symptoms

5. I’ve been diagnosed with positional vertigo. Is it possible for this to return? What can I do to reduce my risk?

Yes. BPPV is known to recur and that incidence is often quoted to be 10% per year meaning a subject with positional vertigo has a 10% chance of having another “attack” in the same year. Any disorder affecting the inner ear such as meniere’s disease as well as vestibular migraine seems to increase the chances of this happening. Also, low levels of vitamin D have been considered a risk factor in bppv and supplementing for vitamin D deficiency is a low cost low risk intervention that may help (jury is still out on this one)

6. Are there medications that can help with my dizziness? Alternatively, are there any medications that could potentially worsen a patient’s symptoms or recovery? What about other treatment options?

During an acute attack of vertigo, meclizine, valium, promethazine may be used. If patient is vomiting, suppositories may be necessary. However, taking them long term is going to affect the brain’s ability to compensate and thus it is not advisable to stay on those medications indefinitely. Depending on the cause of the dizziness, a short course of steroids may be indicated as well as preventive therapy for migraines or for meniere’s disease

7. Imbalance is a significant concern for adults as we age. Why is this the case? Do you have guidance on when to seek out balance therapy resources?

As our population is getting older (a child born today is expected to live to be 130 years old), our sensory systems are aging as well. The same way vision is affected and hearing is affected, balance is also affected. Loss of the function of balance of the ears (vestibular function), loss of proprioception (back pain, hip pain, joint pain , reduced muscle mass) and reduced visual acuity increase dramatically the risk of falls. This in itself cause significant injuries and increase mortality in the elderly. If there is any concern for falls, near falls, hesitant gait or dizziness, a patient needs to be evaluated by a vestibular specialist and started on a vestibular rehab program that will significantly reduce that risk

8. What other specialists might be involved in the diagnosis and management of a patient with a suspected vestibular disorder?

Audiologists to perform an array of vestibular testing that will give us an idea of how the vestibular system is functioning. Vestibular therapists that are primordial in setting up a physical therapy/rehabilitation plan

9. What would you want the general public to know about vestibular disorders?

It is an invisible problem. It can have a significant toll on people from the functional, emotional and even cognitive standpoint. If you have a relative or a friend with a diagnosis of vestibular dysfunction, accepting an injury you cannot see will go a long way helping those patients go on the path to recovery. It is not “in their head”.

10. What is your overall key take home message for providers working with patients with vestibular disorders?

Do not underestimate the pervasive impact of a vestibular dysfunction on your patient’s overall health and functioning. New data even shows potential links with progression to dementia. This goes to say how important is our vestibular function in many dimensions of our lives. A thorough assessment to rule out severe etiologies (tumors, strokes) and to make a good functional assessment, will allow you to establish a multidisciplinary plan of care that should impact their quality of life tremendously.

Habib Rizk, MD, MSc, grew up in Beirut, Lebanon, and is a graduate of the French Faculty of Medicine-Saint Joseph University in Beirut Lebanon. Dr. Rizk completed an Otolaryngology – Head and Neck Surgery (Ear, Nose and Throat, ENT) Residency at Hôtel-Dieu de France Hospital in Beirut with additional fellowship training in Otologic Medicine and Surgery Fellowship with Dr. Michael Teixido as well as in Neurotology at the Medical University of South Carolina (MUSC). He then joined the MUSC ENT Department as the director of the Vestibular Program, and established the only multidisciplinary program in the state of South Carolina to evaluate and manage patients with various causes of dizziness. He is on the board of directors of the American Balance Society, a member of the Equilibrium Committee of the American Academy of Otolaryngology – Head & Neck Surgery as well as a representative of the Academy in a joint task force with the American Academy of Neurology to investigate quality improvement measures in neurotology.

Dr. Rizk is involved in hearing-related and dizziness-related research and has over 25 articles published. He also authored several book chapters and published a book about anatomy of the ear geared toward teaching residents and medical students the complex anatomy of the ear and temporal bone. His interests pertain to all areas of otology and neurotology with a specific focus on medical and surgical management of vestibular disorders.

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