AUDIOLOGY FEATURE Dizziness: confusion, issues and considerations

BY DOUGLAS L BECK

Douglas L Beck gives his unique take on the difficulties involved in diagnosing dizzy patients and the importance of well-founded research acting as the basis for any diagnosis and treatment decisions.

izziness. Uh-oh. We really have that we cannot prove anyone is (or is not) shortage of tests. However, the thing a very limited understanding experiencing dizziness, spinning, light- about tests to unravel dizziness is they of diagnosing and treating headedness (or back pain, tinnitus or support or refute one diagnosis versus Ddizziness. Words like “vertigo”, headaches for that matter!). For example, another, but they generally cannot “dizziness”, “dizzy”, “unsteady”, “spinning” Eggermont (2012) gave a 4000 Hz tone to prove any diagnosis – and to add insult (and more) are not very accurate, they many people, of whom a third described to injury, the treatment prescribed overlap and they mean different things to it as a tone, but two thirds described it may have the same uncertainty issues different people. as something else (26% a hissing sound, (unless, of course, the patient is fortunate Are you spinning? Is the world spinning 18% a roaring sound, and some 22% enough to receive the diagnosis of around you? Is it going left-to-right or described it as whistling, squeaking and benign paroxysmal positional vertigo right-to-left? Are you woozy? Light- more) [1]. The point is, the words used [BPPV], in which case the diagnosis and headed? Do you have hearing loss? by the patient may or may not be in sync treatment are very well defined and the OK, well then, it’s your ear. We’ll need with our understanding of those same treatment [repositioning manoeuvres] to rule out Ménière’s disease and / or words. Their ability to describe signs, is more than 90% successful). However, endolymphatic hydrops and / or benign symptoms and experiences may be if the differential diagnosis is migraine paroxysmal positional vertigo (BPPV)? limited by their experience, vocabulary (or Ménière’s disease or vestibular Wait, did you say you had a headache? and knowledge of the subject matter. migraine) one should query, “What Do other people in your family have Beck, Petrak and Smith (2013) is the gold standard treatment and headaches? Maybe you’re experiencing reported migraine, Ménière’s disease what is the percentage of time that the most common cause of dizziness, a and vestibular migraine do overlap and treatment successfully manages that migraine! Ah hah! Then again, it could be are each known to be a diagnosis of ailment, according to the peer-reviewed your blood pressure. Or maybe it’s your exclusion [2]. Indeed, the term ‘vestibular literature?” diet – perhaps you’re anaemic? Wait – migraine’ may very well be a synonym Oops…not much there! Nelson (June, maybe it’s your vision. It could be you got for migraine associated dizziness, 2011) notes that, “most medications up too fast… or something else entirely. vestibular Ménière’s, migraine associated tailored to stopping migraine headaches, How low is the chair you were sitting vertigo, benign recurrent vertigo, like triptans, do not address the in? Did you eat breakfast today? Did you vertiginous migraine, migraine-related primary manifestation of migraine- lose consciousness? Maybe it’s a brain vestibulopathy and more! Perhaps related dizziness, commonly known as tumour? these diagnoses originate with the same migraine-associated vertigo … despite The thing about “dizziness” is no two issue / phenomenon (pathogenesis) and the continued absence of rigorous clinical people or patients describe it the same perhaps the differences in differential criteria or gold standards of care [italics way. Of course, we all get the concept diagnosis are attributable to the apparent are the author’s] … otolaryngologists – but it’s kinda like back pain, tinnitus manifestation of the problem within are achieving considerable success in and headaches. That is, we know what the particular patient, their vocabulary, treating migraine-associated vertigo, those words mean to us (through our and the education and profession of the using a more ad-hoc strategy that is professional filters) but we don’t actually clinician who makes the diagnosis? based on their own experience, anecdotal know what it specifically means to the The good news is we have tests! Of evidence and therapeutic trial and person who suffers from it – and we know course we have lots of tests. There is no error” [3]. Really? I mean, OK, if I get a headache and dizziness, I really do want someone to help me … but really? Nelson reports, “migraine patients often experience vertigo during headache free periods.” Further, Nelson quotes an otolaryngologist as saying, “Some people, for example, will have a pattern where “The thing about “dizziness” is no two people or they have headaches, and then for a few years they’ll just have vertigo spells, and patients describe it the same way.” then they’ll go back to having headaches

ent and audiology news | NOVEMBER/DECEMBER 2015 | VOL 24 NO 5 | www.entandaudiologynews.com AUDIOLOGY FEATURE

“As clinicians, we need to question everything we do and why we do it.”

again … So the vertigo is sort of the In response to the issues of caffeine in the best interest of the patients, the migraine.” Alas. Now it’s totally clear – or no caffeine pre-test, McCaslin stated professions or our understanding of the although I feel a bit dizzy. “there’s no study that I’m aware of that question asked. According to a postal survey in the shows the patient cannot have caffeine UK in 2005, 52% of otolaryngologists on the morning of their test! Caffeine is References 1. Eggermont JJ. Current Issues in Tinnitus. In: “were actively involved in the treatment fine and it’s not likely to impact the test Translational Perspectives in Auditory Neuroscience. of patients with Ménières disease using an hour or two later, but without caffeine, Tremblay K, Burkard R (Eds). San Diego, CA; Plural a wide range of medical and surgical the patient may be very cranky and some Publishing; 2012. therapies that have little or no evidence 2. Beck DL, Petrak MR, Smith AG. Migraine, Ménière’s may start to get a caffeine-withdrawal disease and vestibular migraine. Audiology Today base [italics are the authors]. The survey headache! So we absolutely let them 2013;March/April:54-60. found that 94% of surgeons prescribe have their coffee!” [5]. 3. Nelson B. A personal spin on migraine associated betahistine, 63% diuretics and 71% advise And finally, I would like to address vertigo treatments – with few formal guidelines, salt restriction to their patients, while otolaryngologists use trial and error. ENT Today 1 dizziness in children. Despite our lack June 2011. 52% of surgeons continue to recommend of scientific knowledge related to 4. Smith WK, Sankar V, Pfleiderer AG. A national saccus decompression and 50% are still dizziness and despite a lack of children survey amongst UK otolaryngologists regarding inserting a grommet” [4]. Yikes! the treatment of Ménière’s disease. J Laryngol Otol complaining about dizziness (children Although salt restrictions make 2005;119(2):102-5. don’t have the vocabulary to describe intuitive sense, and although salt 5. McCaslin DL. American Academy of Audiology dizziness and they may not know that interview. 2013; available at http://www.audiology. restrictions probably have never hurt org/news/vemps-rotational-tests-and-platform- dizziness is bad! Indeed, many children anyone (except in their taste buds), where posturography-interview-devin-l-mccaslin-phd (last take joy in roller coasters and being is the peer-reviewed data showing dietary accessed September 2015). salt restrictions improve the perception upside down on the monkey bars), Beck, 6. Beck DL, Petrak MR, Bahner CL. Advances in pediatric Petrak and Bahner (2010) reported vestibular diagnosis and rehabilitation. Hearing of dizziness? That is, if dietary salt Review, October 2010. vestibular disorders in the paediatric restrictions worked, why are the patients 7. Beck D, Petrak M, Madell J, Cushing S. Update 2015: dizzy for years and years? And what about population are most likely under- Pediatric vestibular, balance, and hearing disorders. our typical test protocol preface, which diagnosed [6]. They stated vestibular Hearing Review January 2015. disorders are indeed “more common in 8. Wolter NE, Gordon KA, Papsin BC, Cushing SL. takes the patient off their medications Vestibular and balance impairment contributes prior to electronystagmography and children with significant hearing loss to cochlear implant failure on children. Otology & other dizziness tests? Does that make and other inner-ear abnormalities”. Neurotology 2015;36:1029-34. sense? Seems to me, we want to test Beck, Petrak, Madell and Cushing them in their current state of being as (2015) reported “vestibular and balance they live their life, with coffee and salt disorders are highly associated with and their daily meds on board. That is, SNHL in children, however, most shouldn’t we evaluate them as they are? professionals don’t screen for vestibular McCaslin (2013), in response to the dysfunction in (these same) children. question of telling patients to discontinue The authors estimated the prevalence their medications prior to balance of vestibular and balance disorders in testing, said “when you tell them to children may be as high as 15% of all discontinue their medications, they may children, and up to 70% of children with accidentally discontinue something they SNHL” [7]. Further, Wolter et al. (2015) should have stayed on, they may get reported an increase in cochlear implant confused, they may have a really bad day failures among children with vestibular on the day of test because they didn’t and balance issues [8]. Specifically, more take medicines they were accustomed than half the children experiencing to – and one never knows the exact cochlear implant failure “had an etiology outcome that could happen if the patient of hearing loss often associated with gets confused or skips an important vestibular disorders (and) bilateral medicine. Bottom line … we do not tell horizontal canal dysfunction, increased them to discontinue their medications. Our current approach is to test the patients the odds of CI failure and need for Douglas L Beck AuD, on their medications and at the time of subsequent re-implantation by eight- fold.” Director of Professional Relations, the appointment and document closely Oticon Inc Somerset, NJ, USA. As clinicians, we need to question which they have taken and when. I will E: [email protected] say that since we have adopted this everything we do and why we do it. We need to create and adhere to best policy, we have not observed any change Declaration of competing interests in the number of patients presenting with practices based on peer-reviewed, None declared. bilateral caloric weaknesses or ocular outcomes-based results (i.e., science). motor impairments” [5]. To do less is folly, and to do less is not

ent and audiology news | NOVEMBER/DECEMBER 2015 | VOL 24 NO 5 | www.entandaudiologynews.com