<div>Secondary care vestibular function testing for management of balance
disorders</div><div>This is a prospective study on the outcome of vestibular function tests
for the investigation of dizziness in patients referred to an ENT
department in a district general hospital in Wales</div><div>Design, setting and participants Videonystagmography (VNG) is carried
out as initial assessment of the integrity of the peripheral vestibular
function in patients with balance dysfunction. The study was carried out
in district general hospital and 110 patients were included in this
study. Patient information were collected with the aid of questionnaire.
Dizziness, a common symptom of imbalance in adults is commonly under
treated and often becomes chronic; it can lead to deterioration in
quality of life with substantial socioeconomic impact. It is a common
problem in patients managed in primary care.</div><div>Main outcome measure The aim of the study was to quantify the number of
patients referred by general practitioners to ENT for investigation and
what proportion were further referred for vestibular function tests.</div><div>Results We wanted to establish the usefulness of VNG in the management
of dizzy patients. In a large proportion of patients it was difficult to
establish the true nature of dizziness.</div><div>Conclusion We found that VNG is useful for exclusion of peripheral
vestibular disorders and often to corroborate adequate vestibule-ocular
reflex.</div><div>Key points</div><div>Dizziness is common, largely untreated and often becomes chronic
resulting in to great personal loss and on large scale economic loss</div><div>The aim of the study was to quantify the number of patients referred by
general practitioners to ENT department for investigation and what
proportion was further referred for vestibular function tests</div><div>Videonystagmography is carried out as initial assessment of the
integrity of the peripheral vestibular function in patients with balance
dysfunction.</div><div>We found that VNG is useful for exclusion of peripheral vestibular
disorders and often to corroborate adequate vestibule-ocular reflex.</div><div>Introduction</div><div>Dizziness is a term used to describe a range of sensations, such as
feeling faint, woozy, and weak or unsteady<sup>6</sup>. It is a
symptom usually described by patients. When present it can be related to
balance dysfunction but this is not always the case. Vertigo is a
sensation of motions or spinning that is often described as dizziness<sup>7</sup>. It is not the same as being lightheaded. Vertigo is
a characteristic manifestation of peripheral vestibular dysfunction
often related to inner ear or vestibular nerve pathology. Clinical
examination can provide some qualitative information of the vestibular
function and differentiate central from peripheral Vestibular
dysfunction. Not every patient with dizziness requires qualitative
vestibular function testing.</div><div>Dizziness is a common symptom presenting to primary care, it is largely
untreated, often becomes chronic with a resulting deterioration in the
patients quality of life and on a larger scale great socioeconomic loss<sup>1</sup>. Balance function deteriorates with age and is one
of the most common reasons for patients aged over 75 to seek advice in
primary care. It has been quoted that almost three million UK residents
suffer from dizziness <sup>2</sup>. Unfortunately the initial
treatment of patients with dizziness is often haphazard and largely
ineffective. It has been reported that one third of dizzy patients
remained symptomatic after five years and only one in four received
treatment. Studies from other countries support the evidence of high
prevalence of dizziness and a large proportion of patients without
treatment.</div><div>2:Material and method</div><div>2.1</div><div>No ethical approval was required as all individual responses were
anonymised</div><div>2.2 Participants</div><div>This is a prospective, single institution observational study of
patients who presented with balance disturbance to the ENT department of
one district general hospital in South West Wales.</div><div>2.3 Setting</div><div>This study was carried out in ENT department of district general
hospital in south Wales. The measurement of main outcome measure was
carried out on patients referred to the audiology department at
Glangwili hospital in Carmarthen for vestibular assessment.</div><div>2.4 Study design</div><div>The data was collected by the help of a questionnaire. We designed 5
questions to see whether videonystagmography helps to deal with patients
who do not fit in to any specific category of ENT vertigo. The
questionnaire were given to our audiologist who performed the
videonystagmography and recorded the results according to questionnaire.
All vestibular function tests were performed by same audiologist.
Research protocol included exclusion criteria which was, age under 18
years, patients unable to tolerate VNG and history of ear surgery with
open mastoid cavity. majority of patients with a clear history and
clinical presentation of vertigo due to peripheral vestibular
dysfunction, were diagnosed and treated accordingly. Subsets of patients
presenting atypical clinical findings were sent for vestibular function
testing for further investigation to aid to diagnosis. Simple
statistical analysis were performed to analyse data. Data collection was
based on a five-question pro forma:</div><div>Data collection form</div><div>Pertinent information was collected with the aid of a questionnaire as
follows:</div><div>Numbers of patients referred to ENT by primary care.</div><div>Number of patients referred from ENT to Audiology for vestibular
assessment (vestibular function tests).</div><div>Main purpose of referral: Detection of vestibular dysfunction or
confirmation of integrity of vestibular portion of balance system (
vestibulo-ocular reflex).</div><div>Outcome of investigation. Detection of vestibular dysfunction or
confirmation of integrity of peripheral vestibular system.</div><div>Was further management required: ENT, Audiology, and Neurology?</div><div>Results</div><div>The average total number of patients referred to ENT was 5400 in one
year. Of these on average 343 were referred for investigation of balance
disturbance (vertigo is mentioned but in the referral it is not always
clear). Furthermore 130 out of these 343 patients on average were
referred for vestibular function tests. Our study was conducted for 10
months and 110 patients were included. 20 patients did not fulfil the
inclusion criteria and therefore were excluded. The outcome of the study
showed that 37 patients were referred for vestibular rehabilitation that
were continuously dizzy and were difficult to place in to any specific
ENT dizziness. In these 37 patients VNG did show some weakness of one
sided peripheral vestibular function. 41 Patients showed normal
vestibular function test with no further complaint of dizziness and were
discharged back to their GP. 14 patients were found to have BPPV (benign
paroxysmal vertigo) and underwent Epley’s manoeuvre with no further
follow up required. The remaining 18 patients who were referred back to
ENT department had normal VNG but still were very symptomatic with
dizziness. These patients were referred to neurology for their opinion
and further management.</div><div>Management</div><div>Dizziness increases with age and around one third of the population in
50-60 years of age suffer with this problem <sup>3</sup>.</div><div>. Over 75 years of age dizziness is the most common cause to seek a
general practice consultation <sup>4</sup>. Despite this the
treatment is haphazard and largely ineffective. Yardley et.al reported
that 1/3 of the patients with dizziness remained symptomatic after 5
years and only ¼ ever received treatment <sup>5</sup>. Peripheral
dizziness can easily be distinguished from central dizziness by simple
bedside test. Negative head impulse test, direction reversing
gaze-evoked nystagmus and vertical skew deviation suggest central
vestibular lesion <sup>8</sup>. On the other hand positive head
impulse test, unilateral nystagmus and no vertical skew deviation
indicate peripheral vestibular lesion <sup>9</sup>.</div><div>Videonystagmography is a useful test to exclude any peripheral
vestibular disorder. There are more than 3 million people with dizziness
but still very poorly managed. 14 patients who were diagnosed as BPPV
could have easily been managed in the clinic rather than being referred
for vestibular function test. We feel that dedicated clinics are
required to deal with dizzy patients at a district general hospital and
preferably it should be a one stop clinic including ENT surgeon,
Audiologist and or neurologist.</div><div>References</div><div>Eaton DA, Roland PS. Dizziness in the older adult. Part 1. Evaluation
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